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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426200093
Report Date: 06/29/2021
Date Signed: 06/29/2021 11:52:42 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:ST. RAPHAEL SCHOOL/PRESCHOOLFACILITY NUMBER:
426200093
ADMINISTRATOR:SANTOS, EDNA L.FACILITY TYPE:
850
ADDRESS:160 ST. JOSEPH STREETTELEPHONE:
(805) 967-4435
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:27CENSUS: 15DATE:
06/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Edna SantosTIME COMPLETED:
12:00 PM
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A case management inspection was conducted by LPA S. Mendoza-Ceja who met with the Director Edna Santos. The purpose of the inspection was to review the incident that occurred on 06/21/2021. The Director reported the incident and submitted the incident report to the Department as required.

On 06/21/2021, Child #1 was climbing on the play structure, lost her balance, and fell landing on her left wrist. Child #1's parent was contacted and arrived within 10 minutes. Child #1 sustained an injury requiring medical treatment. Child #1 sustained fracture to her left wrist. The incident was observed by the Director and staff, the teacher:child ratio was 2:15 on the day of the incident. Today, LPA inspected the play structure and observed it to have appropriate cushioning for the fall zone.



Failure to Post the Notice of Site Visit for 30 days may result in a $100.00 Civil Penalty.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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