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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566210209
Report Date: 01/03/2020
Date Signed: 01/03/2020 12:16:18 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:CDR - BERYLWOOD HEAD START CENTERFACILITY NUMBER:
566210209
ADMINISTRATOR:SUZANNE GODINEZFACILITY TYPE:
850
ADDRESS:2300 HEYWOOD ST.TELEPHONE:
(805) 583-3775
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:43CENSUS: 28DATE:
01/03/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Jennie WillTIME COMPLETED:
10:20 AM
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Licensing Program Analysts (LPAs) Betzayra Cervantes and Francisco Pedroza made an unannounced visit for the purpose of conducting a Case Management - Incident inspection. LPAs met with Site Supervisor Jennie Will and discussed the nature and purpose of the visit. LPA's and Site Supervisor Will conducted a tour of the facility inside and outside.

On 12/12/2019, the facility self reported an incident to Community Care Licensing where a child (C1) sustained an injury to the left eye and required medical treatment. The incident occurred at/or around 9:30 AM where a child (C1) ran into the ring of a dancing ribbon while twirling outside on the playground. Staff (S1) was dancing with another child (C2) who was using a dancing ribbon to make large circles. C1 was near the play structure and began to move near the bike path towards where C2 was dancing and ran into the plastic ring of the ribbon striking the left eye causing the eye to swell.

Staff (S2) immediately applied first-aid to the child while at the same time contacting the child's parent. The parent was unable to be reached and was later picked up by the babysitter at 2 PM and given an incident report. The parent informed the facility that the child will seek medical attention given that she has a preexisting medical condition. Site Supervisor Will advised that C1 has a temporary Incidental Medical Services (IMS) plan. LPA's reviewed staff and the child's records.

Based on the information obtained from today's unannounced visit, LPA's determined staff provided adequate supervision and took appropriate action.

No deficiencies were issued as a result of this inspection.

SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Betzayra CervantesTELEPHONE: (805) 680-7175
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2020
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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