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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566208287
Report Date: 10/09/2019
Date Signed: 10/09/2019 04:00:45 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:VUSD - PORTOLA JUMPSTART STATE PRESCHOOL PROGRAMFACILITY NUMBER:
566208287
ADMINISTRATOR:KATE HENGGELERFACILITY TYPE:
850
ADDRESS:6700 EAGLE ST.TELEPHONE:
(805) 289-1734
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:24CENSUS: 20DATE:
10/09/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Neomi JimenezTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jill Laxo made an unannounced inspection for the purpose of conducting a Case Management Incident evaluation. LPA Laxo met with Director Neomi Jimenez and discussed the nature and purpose of the inspection.

On June 10, 2019, the Director self reported an incident which occurred outside on the playground on 06/03/2019. C1 was standing on a play structure which has staggered, plastic, wide semi circle shaped steps when a second child C2 pushed C1 causing them to fall. C1 fell on their right arm/elbow bracing the fall. All staff S1, S2, and S3 were outside when the incident occurred. C1 was taken into the classroom and ice applied to the right arm. C1 parent was notified and C1 was picked up and taken home and later to emergency. C1 sustained a broken elbow which required surgery. Due to the program closure for summer, C1 did not return to school until August 21, 2019.

Director Jimenez showed LPA the play structure and the location of the incident. The play structure is in the center of the play area and has a cushioned padding underneath. Staff was standing close and witnessed the fall. Based on information reported on the Unusual Incident Report, facility records, and Director statements, LPA deemed Directors action was appropriate.

No Deficiencies were sited today.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0347
LICENSING EVALUATOR NAME: Jill M Hazelhofer-LaxoTELEPHONE: (805) 635-5097
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2019
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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