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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426207802
Report Date: 02/17/2023
Date Signed: 02/17/2023 01:16:55 PM


Document Has Been Signed on 02/17/2023 01:16 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:CAC - "I" STREET CENTERFACILITY NUMBER:
426207802
ADMINISTRATOR:NOHEMY ESTRADAFACILITY TYPE:
850
ADDRESS:228 NORTH I ST.TELEPHONE:
(805) 735-8392
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:38CENSUS: DATE:
02/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Shonna MartinTIME COMPLETED:
01:20 PM
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On February 17th, 2023, at 1:03PM, Licensing Program Analyst (LPA) Rosie Breault made an unannounced visit for the purpose of conducting a Case Management - Incident inspection. LPA met with facility director Shonna Martin and discussed the purpose of the visit. LPA and licensee conducted a tour of the facility inside and out. At the time of the inspection there were twenty-five (25) children, and five (5) teachers present.

On 2/10/2023 Shonna Martina contacted Community Care Licensing (CCL) to self-report an incident of a child disclosing confidential information to a teacher. Both teacher and director contacted Child Welfare Services (CWS) who responded on site that day, and child disclosed further information to the representative of that agency.

Child has returned to facility (no absence occurring). Child mother and father contacted director separately and director provided number of CWS to both. Parents have not disclosed information to teacher or staff. Father came to center on 1/13/2023 (please note, facility closed for staff day), informed Family Service Advocate that incident was not true, and left director a message. Director returned call and left a message with CWS contact information. Director called CWS prior to confirm father could contact agency directly. Child has not discussed matter further and remains enrolled.

Director reported incident to CCL immediately and provided SCAR and report.

No deficiencies were cited during today's visit.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0347
LICENSING EVALUATOR NAME: Maryrose BreaultTELEPHONE: (805) 635-5097
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023
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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