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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566210498
Report Date: 05/17/2019
Date Signed: 05/17/2019 11:59:07 AM

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:CDI - HAYCOXFACILITY NUMBER:
566210498
ADMINISTRATOR:RACHEL CHAMPAGNEFACILITY TYPE:
850
ADDRESS:5400 PERKINS RD.TELEPHONE:
(805) 488-3578
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:24CENSUS: 22DATE:
05/17/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cecila LopezTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Michael Avila made an unannounced visit for the purpose of conducting a Case Management inspection to follow up on an incident where the the facility reported a child injury. LPA Avila met with Site Supervisor Cecilia Lopez and discussed the nature and purpose of the visit.

On 4/26/2019, on/or about 5pm a child (C1) laying on top of a large bouncy ball, fell and injured his left arm. Staff observed the incident and applied ice to the child's arm while staff called the mother pick up the child. Given the type of work the mother was employed in, the mother was not able to immediately able to pick up her child. Staff having observed the child utilizing his left arm did not deem the child's injury as urgent and waited until the mother arrived about 45 after the incident. The child was taken to seek medical attention where it was determined the child had a strain left shoulder. Given the language barrier of the family, The parent has not provided a physician report so it was unclear as to the extent of the child's left shoulder's injury.

The facility acted in accordance with their protocol in providing care and visual supervision, applying first-aid and contacting the child's authorize representative.

No deficiencies were issued as a result of this incident.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Michael AvilaTELEPHONE: (805) 722-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2019
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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