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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426212030
Report Date: 04/28/2021
Date Signed: 12/22/2023 09:45:03 AM


Document Has Been Signed on 12/22/2023 09:45 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/01/2023 11:59 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

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The purpose of this amendment is to update the administrator's name.

On April 28, 2021 at 1:30PM, Licensing Program Analyst (LPA) Sylvia Mendoza-Ceja conducted an unannounced tele-inspection via Facetime due to COVID-19 State of Emergency in order to conclude the investigation of the alleged incident which was reported to the Department as required on February 26, 2021.



LPA met with Site Supervisor Alicia Jimenez and advised her the purpose of the inspection. The incident was alleged to have occurred during an off site field trip with another local company on February 5, 2021 in regards to a Personal Rights Violation. The investigation was lead by Investigations Branch Investigator Tiffany Brunelli.

Site Supervisor Alicia Jimenez escorted LPA through the center, LPA observed the children resting during the nap time.

This agency has investigated the incident alleging Personal Rights Violation.
Based on review of records and interviews, reveal no violation occurred.
Exit interview was conducted with Site Supervisor, via tele-inspection, during which appeal rights were explained. This report along with a copy of the appeal rights and Notice of Site Visit (LIC9213) will be sent to the Site Supervisor via email with a read receipt or confirmation of receipt of email, which will act as the Site Supervisor's signature.

Failure to Post the Notice of Site Visit for 30 days may Restult in a $100.00 Civil Penalty.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2021
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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