<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215638
Report Date: 10/12/2022
Date Signed: 10/12/2022 02:22:28 PM


Document Has Been Signed on 10/12/2022 02:22 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:PROVIDENCE PRESCHOOLFACILITY NUMBER:
426215638
ADMINISTRATOR:DESIREE FELLERFACILITY TYPE:
850
ADDRESS:3225 CALLE PINONTELEPHONE:
(805) 962-3091
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:72CENSUS: 63DATE:
10/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Desiree FellerTIME COMPLETED:
02:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On October 12, 2022 at 2:15PM Licensing Program Analyst (LPA) Rosie Breault made an unannounced inspection for the purpose of conducting a Case Management - Incident inspection. LPA conducted a Covid-19 prescreening and no exposure on site. LPA met with facility Director Desiree Feller and discussed the purpose of the inspection. LPA and licensee conducted a tour of the facility inside and out.

On 9/28/2022, licensee contacted Community Care Licensing (CCL) to self-report an incident of a child jumping on a therapeutic mini trampoline and fracturing wrist.

Director stated teacher Bayli Morrow was watching C1 jump on a mini, therapeutic sensory based trampoline a few inches off the ground with no other children present on equipment. LPA requested to speak with Ms. Morrow who stated C1, age 4 ½ lost balance and fell forward on left wrist. C1 indicated there was pain, however no blood present. Teacher applied ice to C1 and called mother 20 minutes later. Mother picked up C1 and subsequently took to the doctor. C1 returned to school the following scheduled date with a splint which was then changed to a cast. Mother did not indicate any pain medication or ointments to be given to child. In speaking with director, LPA advised director to not have that piece of sensory equipment and LPA saw director remove it off the play yard.

No deficiencies were cited during today's visit.

A Notice of Site visit was posted.

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0347
LICENSING EVALUATOR NAME: Maryrose BreaultTELEPHONE: (805) 635-5097
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1