561711699-11-20-2019-17-CC-FPEA-BJ4QDW-20191120110526

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561711699
Report Date: 11/20/2019
Date Signed: 11/20/2019 11:05:32 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 CENTER		FACILITY NUMBER:	561711699
ADMINISTRATOR:	MICHELLE GORDON		FACILITY TYPE:	850
ADDRESS:	2372 ERRINGER ROAD		TELEPHONE:	(805) 526-2887
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	120	CENSUS: 63	DATE:	11/20/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Michelle Gordon		TIME COMPLETED:	11:20 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 conducted an unannounced inspection for the purpose of conducting a Case Management - Incident inspection. LPA met with facility Director Michelle Gordon and discussed the purpose of the inspection. LPA and Director together toured of the facility inside and out. There was 63 children in care at the time of the inspection. On 10/24/2019, Director Gordon contacted LPA Pedroza to self report an incident of a child sustaining an injury while in care. On 10/23/2019 there was 36 children playing on the outdoor play area with six teachers supervising them. Children were playing on the grass area, sandbox, structures, and riding tricycles. C1 was playing on the grass area and started to run to the sand box area. There is a six foot wide concrete sidewalk area separating the grass area from the sandbox where children ride the tricycles on. C1 collided with a child riding a tricycle. Two of the teachers that were closer to C1 immediately responded to provide him with care. C1 was crying and did not want to move. Staff carried him away from the area attempted to provide an ice pack for his left leg that was hurting. C1 declined the ice pack. Staff carried C1 to the office and his mother was contacted. C1's mother attempted to see if the he wanted to stay at school and refused. C1 was signed out for the day. Continued on 809-C

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2019

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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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: 11/20/2019

NARRATIVE

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C1 went to the urgent care and was diagnosed with a fracture on his left shin. His left leg was placed in a full cast. C1 has not returned back to the facility. Director Gordon informed LPA that he was going to be out for the whole month of November. Director advised that C1's mother was informed that the facility will require a doctor's note when C1 returns so the facility can address any needs and restrictions.

LPA observed where the child had collided into the child riding the tricycle. LPA spoke with Director about what steps the facility can to take to minimize an incident like this again. Director stated that they have talked with children about not crossing and wait until children riding tricycles pass. They will continue to provide enough staff to supervise and monitor children. Given the licensee's account of the incident when reporting it to LPA 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 Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2019

LIC809 (FAS) - (06/04)

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