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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426205725
Report Date: 08/09/2022
Date Signed: 08/09/2022 03:02:59 PM


Document Has Been Signed on 08/09/2022 03:02 PM - It Cannot Be Edited

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:CAPSLO - BONITA MIGRANT AND SEASONAL HEAD STARTFACILITY NUMBER:
426205725
ADMINISTRATOR:A.RAMIREZ-BARRONFACILITY TYPE:
850
ADDRESS:4685 EAST 11TH STREETTELEPHONE:
(805) 343-0324
CITY:GUADALUPESTATE: CAZIP CODE:
93434
CAPACITY:40CENSUS: 14DATE:
08/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Pamela PanoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Martina Jimenez conducted an unannounced Case Management Inspection. LPA met with Pamela Pano, Lead Teacher, regarding the incidents which occurred 08/02/2022, and 08/03/2022. A risk assessment was conducted by LPA prior to entry into the center.

The incident was reported to the Department as required. LPA reviewed child #1 file. The incident was found to be appropriately handled by the center. The center will continue to monitor child#1 behavior with one on one shadowing.

No deficiency cited.

FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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