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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566207355
Report Date: 12/23/2020
Date Signed: 12/23/2020 06:43:12 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:CAMP AMGENFACILITY NUMBER:
566207355
ADMINISTRATOR:JENNIFER MCHUGHFACILITY TYPE:
850
ADDRESS:855 VENTU PARK RD.TELEPHONE:
(805) 447-6793
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:324CENSUS: 6DATE:
12/23/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH: Leyla Pinstent, Program DirectorTIME COMPLETED:
04:45 PM
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On 12/23/2020 at 4:15 pm Licensing Program Analyst (LPA) M. McDaniels called and spoke with Program Director, Leyla Pincet to conduct a Case Management inspection to follow up an Unusual Incident Report( UIR) reported by the facility. Due to the COVID -19 and Department of Public Health guidelines of social distancing, a tele-inspection was conducted via Facetime. LPA explained the nature and purpose of the Virtual Visit to the Director.
On 09/17/2020 C1 was walking to the bathroom; lost his balance, fell forward, hitting
his head on the bathroom sink. C1 received a 3/4 inch cut on the middle of his forehead.
First aid was given- Teacher applied pressure to the forehead. C1's mother and ambulance were
called. C1 was assessed by the paramedics and taken to the hospital. C1 received 6 stitches on the middle of his forehead.
During the time of the inspection there were 6 children and 2 adults present. LPA observed the classroom and the bathroom where the injury occurred. There was a black industrial rug on the floor under the sink with a rubber bottom and a rug on top. There was no water observed on the ground. LPA observed no potential hazards or risks during the inspection.
LPA interviewed the Staff that was present when the injury occurred. S 1 stated that the child's shoe was to big and slipped off while walking to the sink. S 1 stated their were 10 children and 2 adults on the date and time of the incident.
This incident was deemed an accident.
An exit interview was conducted. A copy of this report was reviewed and provided to the director who agreed to receive a copy of report via email and voiced understanding that the read receipt confirmation from email will be in lieu of her signature once she received the report.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Maria McDanielsTELEPHONE: (805) 729-8797
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
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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