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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561711931
Report Date: 06/13/2023
Date Signed: 06/13/2023 12:59:28 PM

Document Has Been Signed on 06/13/2023 12:59 PM - It Cannot Be Edited

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:VUSD - JUMPSTART (MONTALVO)FACILITY NUMBER:
561711931
ADMINISTRATOR:LORETTA GALAVIZFACILITY TYPE:
850
ADDRESS:2050 GRAND AVENUETELEPHONE:
(805) 289-1872
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 18DATE:
06/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Ruth ValenciaTIME COMPLETED:
01:15 PM
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On June 13, 2023, Licensing Program Analyst (LPA) Susana Martinez made an unannounced visit for the purpose of conducting a Case Management inspection. LPA met with Ruth Valencia (site supervisor) to discuss an incident that was self reported to Community Care Licensing Division (CCLD) office by phone on 05/31/2023. LPA toured the area where the incident occurred and interviewed Director. At the time of inspection there were 18 children along with 3 staff.

On 5/30/23 an incident occurred at the center at around 2 pm. A child (C1) was playing outside on the playground structure, missed a step and fell on arm. Two staff members (S1 and S2) observed the incident. S1 and S2 immobilized C1's arm and contacted the site nurse who provided ice to the child, and called C1's parents. The child was taken to the doctor and was given a cast.

Director states the child has returned to the facility on June 7th days without restrictions. LPA observed the child in care with the cast on. To prevent any similar incidents, the director and staff stand closer to the play structure and ask kids to walk down the structure.

Given the incident was observed by staff who took appropriate action by contacting the site nurse, calling the child's parents and reporting incident to CCLD, no deficiencies are being issued as a result of this incident.

Notice of site visit was given, and should remain posted for a minimum of 30 days.

Exit interview conducted and report reviewed with site supervisor Ruth Valencia.
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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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