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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 426200008
Report Date: 09/01/2022
Date Signed: 09/01/2022 10:39:45 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2022 and conducted by Evaluator Martina Jimenez
COMPLAINT CONTROL NUMBER: 17-CC-20220609112724
FACILITY NAME:CAC - ADAM CENTERFACILITY NUMBER:
426200008
ADMINISTRATOR:STACEY LARAFACILITY TYPE:
850
ADDRESS:500 W. WINDSOR ST.TELEPHONE:
(805) 925-6667
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:24CENSUS: 7DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angelica HernandezTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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1. Staff caused injury to day-care child.
2. Staff hit day-care child.
3. Staff handled day-care children in a rough manner.
INVESTIGATION FINDINGS:
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Due to COVID-19 pandemic, LPA asked the pre-screening questions prior to inspection. FAS responses indicate there was no COVID-19 exposure on site.

Licensing Program Analyst (LPA) Martina Jimenez conducted an unannounced inspection to conclude the complaint. The complaint was initiated on June 13, 2022. The investigation included obtaining the child care roster, obtaining complainant's statement, interviewing Site Supervisor, staff and some of the parents of children in care.

The complainant was not available for additional information. The parents interviewed indicated they are satisfied with the care and supervision their children receive. The parent interviews did not corroborate complainant's allegation.

This report continues on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 17-CC-20220609112724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: CAC - ADAM CENTER
FACILITY NUMBER: 426200008
VISIT DATE: 09/01/2022
NARRATIVE
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The allegations are unsubstantiated, based on LPA's interviews with Site Supervisor, staff and parents of children in care. Although the allegation may have occurred, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore, the allegations listed above are deemed UNSUBSTANTIATED.

Exit interview was conducted with the Site Supervisor during which time appeal rights were explained.
This report and appeal rights and Notice of Site Visit (LIC9213) were provided.

THIS REPORT MUST BE FILED IN FACILITY FILE AND MADE AVAILABLE FOR PUBLIC REVIEW FOR 3 YEARS. LPA observed the "Notice of Site Visit" posted. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2