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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561710730
Report Date: 10/10/2019
Date Signed: 10/10/2019 01:40:24 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:ROOTS & WINGS FAMILY DEVELOPMENT CENTERFACILITY NUMBER:
561710730
ADMINISTRATOR:ELIZABETH STRASSWYKFACILITY TYPE:
850
ADDRESS:1492 CALLE TULIPANTELEPHONE:
(805) 492-8560
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:43CENSUS: 22DATE:
10/10/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Michelle WilcoxTIME COMPLETED:
01:50 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
Licensing Program Analyst (LPA) Frank Pedroza made an unannounced visit for the purpose of conducting a Case Management - Incident inspection. LPA met with facility Director Michelle Wilcox and discussed the purpose of the visit. LPA and licensee conducted a tour of the facility inside and out.

On 7/19/2019, facility contacted Community Care Licensing (CCL) to self report an incident of a child (C1) sustaining an injury while in care. On 7/19/2019 at/or around 9:00 AM, C1 was playing outside on some blocks. He fell back and hit the back of his head on a log. Teacher S1 witnessed the incident occur. C1's mother was contacted immediately. She arrived and took him to the Emergency Room. C1 was diagnosed with a laceration and received three staples on the back of his head. C1 returned back to school on 07/30/2019. There was no modified activity request (MAR) provided by the doctor.

LPA observed where the child had fallen. Given the licensee's account of the incident when reporting it to CCL and how they addressed the incident, LPA deemed licensee's action was appropriate.

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: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2019
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