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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561711699
Report Date: 05/17/2019
Date Signed: 05/17/2019 11:20:19 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
FACILITY NAME:CROSS ROADS CHILDREN'S CENTERFACILITY NUMBER:
561711699
ADMINISTRATOR:MICHELLE GORDONFACILITY TYPE:
850
ADDRESS:2372 ERRINGER ROADTELEPHONE:
(805) 526-2887
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:120CENSUS: 51DATE:
05/17/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Michelle GordonTIME COMPLETED:
11:25 AM
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 Gordon and discussed the purpose of the visit. LPA and licensee conducted a tour of the facility inside and out.

On 5/14/2019, licensee contacted Community Care Licensing (CCL) to self report an incident of a child sustaining an injury while in care. On 5/13/2019 at/or around 4:30 PM, a child was climbing up the side of the playground stairs and fell down on to the sand while attempting to touch the side of the slide. The child sat down and began to cry. Teacher Colleen Haiden immediately went to assist the child. After a while the child attempted walk, but was not able to put weight on his left leg. Teacher Haiden then carried the child to the office where he was given an ice pack and his mother contacted. Shortly thereafter the child was picked up by his mother and taken to the emergency room.

The child received medical care and was diagnosed with a fracture under his left knee. His left leg was placed in a full cast. Per the doctor note he was allowed to return back to school on 5/15/2019. The doctor provided a modified activity request (MAR) for the child. Continued on 809C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2019
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 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: CROSS ROADS CHILDREN'S CENTER
FACILITY NUMBER: 561711699
VISIT DATE: 05/17/2019
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
26
27
28
29
30
31
32
Per the MAR the following restrictions/limitations noted by the doctor:
No physical education
No sandbox.

According to the facility staff the child will return back to care on 05/20/2019. They have developed a suitable plan to address his needs while the other children are outdoors for recreation. 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 for this incident today.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2