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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561711699
Report Date: 09/20/2019
Date Signed: 09/20/2019 02:01:58 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: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: 39DATE:
09/20/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Michelle GordonTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Francisco Pedroza and Betzayra Cervantes made an unannounced visit to conduct a Case Management - Incident inspection. LPAs met with facility Director Michelle Gordon and advised her the purpose and nature of the inspection. LPAs and Director together toured the facility inside and out. There were 39 children in care at the time of the inspection.

On 09/17/2019, at around 8:45 am, C1 was playing on the outdoor play structure located in the sandbox. C1 was attempting to go down the the structure steps and fell down. Other children observed the incident happen and went to get the teacher. T1 was alerted by the other children advising that C1 was crying in the sandbox. T1 went to assist C1 and escorted him to the outdoor bench. C1 was provided an ice pack for his arm. T2 observed C1's arm was swollen. She questioned C1 on what had happened and escorted him to the front office where his mother was contacted. C1's father arrived and took him to the local Emergency Room (ER). C1 was diagnosed with a fractured left elbow. C1's arm was placed in a hard cast with a sling.

Continued on 809-C.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2019
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: 09/20/2019
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On 09/18/2019, C1 returned back to the facility with a doctor's note. The doctor provided a modified activity request (MAR) for the child. Per the MAR the following restrictions/limitations noted by the doctor:

No physical education 09/17/2019 - 10/27/2019.
Modified School attendance 09/18/2019 - 10/27/2019.

According to the facility staff the child returned back to care on 09/18/2019. They have developed a suitable plan to address his needs while the other children are outdoors for recreation. Child is placed in another classroom and not allowed to use the sandbox. LPAs 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, LPAs deemed the licensee's action as appropriate. LPAs advised Director to have their staff positioned in better locations so they can have a better visual of the outdoor play area at all times.

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: 09/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2