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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561701617
Report Date: 12/22/2021
Date Signed: 12/22/2021 12:28:55 PM

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:CDR - COLONIA HEAD STARTFACILITY NUMBER:
561701617
ADMINISTRATOR:SUZANNE GODINEZFACILITY TYPE:
850
ADDRESS:1500 COLONIA ROADTELEPHONE:
(805) 486-0850
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:30CENSUS: 0DATE:
12/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maricela LeonTIME COMPLETED:
12:40 PM
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On December 22, 2021 at 11:30AM, Licensing Program Analyst (LPA) Betzayra Cervantes made an unannounced visit to conduct Case Management - Incident inspection. LPA met with Site Supervisor Maricela Leon and discussed the nature and purpose of the visit and together a tour of the facility was conducted both inside and outside. There were no children in care at the time of the inspection.

On 12/16/2021, the center self reported to Community Care Licensing (CCL) an incident that occurred on 12/15/21 at or around 9:47AM where Child #1 sustained a laceration to the forehead requiring 4 stiches. There were 5 children under the care and supervisor of 2 staff. The children were playing outside on the playground. Staff #1 was at the tables with the children when Child #1 got up and began to run to the play structure. Staff #2 immediately began to follow C1 to the play structure. At that point, C1 stopped at the steps of the play structure and missteped on the stairs, resulting with her falling and hitting her forehead on the play structure. According the staff interviews, C1 began to cry and was bleeding from the injury. S2 inspected the injury and cleaned the area and applied gauze. S2 also offered an ice pack, but the child refused. S2 provided comfort and consoled the child while C1's parents were notified of the incident.

C1's mother arrived within 5 minutes of the incident and took her to the local Emergency Room (ER). C1 was diagnosed with a forehead laceration and was given 4 stiches. Site Supervisor stated that C1's stiches are being removed on 12/22/21. C1 has not returned back to the facility due to the center being closed for the Holidays. Site Supervisor informed LPA that center has been in communication with C1's mother and is tentatively scheduled to return in January.

CONT ON LIC 809-C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Betzayra CervantesTELEPHONE: (805) 680-7175
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: CDR - COLONIA HEAD START
FACILITY NUMBER: 561701617
VISIT DATE: 12/22/2021
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LPA observed where the C1's injury occurred. LPA spoke with Site Supervisor about what steps the facility can to take to minimize an incident like this again. Staff reviewed classroom expectations with children and staff will continue to provide active supervision and zoning in the play yard. Site Supervisor reviewed safety practices, and first aid procedures with staff and reminded children on how to play safely and use the equipment.

Based on the information obtained from staff interviews as well as the LPA's observations, LPA determined there were no deficiencies and that CCC functioned in accordance with Title 22 regulations.



No deficiencies were cited during today's visit. Exit interview conducted and report was reviewed with the Site Supervisor, Maricela Leon.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Betzayra CervantesTELEPHONE: (805) 680-7175
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC809 (FAS) - (06/04)
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