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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426210569
Report Date: 11/20/2024
Date Signed: 11/20/2024 02:38:57 PM

Document Has Been Signed on 11/20/2024 02:38 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:EVERGREEN LEARNING CENTER, LLCFACILITY NUMBER:
426210569
ADMINISTRATOR/
DIRECTOR:		LORETTA SMARGONFACILITY TYPE:
850
ADDRESS:7631 EVERGREEN DR.TELEPHONE:
(805) 685-7725
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 42DATE:
11/20/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Keri MulgrewTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On November 20, 2024 at 11:30 AM, Licensing Program Analyst (LPA) Susana Martinez conducted an unannounced Required-3 Year inspection. LPA met with director Keri Mulgrew and advised her the purpose of the inspection. Director provided LPA a tour of the facility inside and out. Center operates M-F 7:30 AM- 5:30 PM. The center has a toddler option. At the time of inspection there were 42 children, 7 of which are toddlers, in the care of 9 staff.

LPA observed required licensing documents mounted on the wall at the entrance of the facility. Last fire drill was observed to be conducted on 10/01/2024. LPA observed the daily activity schedule and snack menu posted at the entrance of the facility. The toddlers classroom is separated from the other children. Both rooms were observed to be equipped with age-appropriate furnishings. LPA observed enough restrooms available for children to use. LPA did not observe any hazards/toxins items accessible to children. First Aid kits were observed throughout the facility. Currently the facility uses an App called Brightwheel for sign-in/sign-out. Facility provides morning and afternoon snacks. Lunch is brought home from the children's homes.
The toddlers use a separate outdoor playground from the rest of the children. Both outdoor play yards are shaded and have an ample amount of space for children to play. LPA observed the playground has age-appropriate toys and structures available for children to use. LPA reminded director that waste containers must have a tight fitting lid.
A sampling of children and staff records were reviewed. LPA observed children's files to be complete and current. LPA reviewed 5 random staff files. LPA found 4 out of 5 staff's mandated reporter certifications to be out of compliance. Director states she will have all employees complete the training. LPA verified SB792 Child Care Adult Immunization and Tuberculosis requirements. During record review it was determined that one staff (S1) on the premises whom has been working since August 2024 did not have a valid criminal record clearance. LPA observed S1 leave the premises. At least one staff member at the facility has valid Pediatric CPR/First Aid which expires on 10/25.
Continued on 809-C
Ana TolentinoTELEPHONE: (805) 562-0437
Susana MartinezTELEPHONE: 805-689-4212
DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: EVERGREEN LEARNING CENTER, LLC
FACILITY NUMBER: 426210569
VISIT DATE: 11/20/2024
NARRATIVE
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Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.
LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

LPA discussed the safe sleep regulations with director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. Director states they have not been documenting the 15 minute safe sleep checks for infants under 24 months of age as she was unaware of requirement. LPA also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
Continued on 809-C
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: EVERGREEN LEARNING CENTER, LLC
FACILITY NUMBER: 426210569
VISIT DATE: 11/20/2024
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

LPA Martinez informed Director Keri Mulgrew that this report dated 11/20/2024 documents One Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Martinez informed the Director Keri Mulgrew to provide a copy of this licensing report dated 11/20/2024 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Two deficiencies were cited today. One Type A and one Type B which can be found on the attached 809-D page.

LPA provided the following resources:

- PIN 20-24-CCP RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT


- SAFE SLEEP FAQ's
- SAFE SLEEP CHART TEMPLATE

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed with director Keri Mulgrew.

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 02:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117


FACILITY NAME: EVERGREEN LEARNING CENTER, LLC
FACILITY NUMBER: 426210569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one staff member does not have a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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LPA Martinez observed staff (S1) leaving the premises. LPA reminded director that employees must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. Proof of criminal record clearance or exemption must be kept in the employees files at all times.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana TolentinoTELEPHONE: (805) 562-0437
Susana MartinezTELEPHONE: 805-689-4212

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024

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Document Has Been Signed on 11/20/2024 02:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117


FACILITY NAME: EVERGREEN LEARNING CENTER, LLC
FACILITY NUMBER: 426210569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 4 out of 5 staff are missing the mandated reporter certificate training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Director is to submit proof of mandated reporter training certification for all employees who were found to be out of compliance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana TolentinoTELEPHONE: (805) 562-0437
Susana MartinezTELEPHONE: 805-689-4212

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024

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