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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566212166
Report Date: 03/05/2020
Date Signed: 03/05/2020 12:19:22 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 - RIO ROASLES HEAD STARTFACILITY NUMBER:
566212166
ADMINISTRATOR:SUZANNE GODINEZFACILITY TYPE:
850
ADDRESS:1001 KOHALA ST.TELEPHONE:
(805) 278-2313
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:46CENSUS: 35DATE:
03/05/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Darlene GoodrichTIME COMPLETED:
12:31 PM
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On March 5, 2020 at 9:00 AM, Licensing Program Analyst (LPA) Betzayra Cervantes made an unannounced visit for the purpose of conducting a Case Management - Incident inspection. LPA Cervantes met with Site Supervisor Darlene Goodrich and discussed the nature and purpose of the visit. LPA observed 35 children under the care of six staff including the Site Supervisor. LPA and Site Supervisor toured the facility inside and outside.

On 12/04/2019, the facility self reported an incident where a child (C1) had his right arm dislocated while playing out in the playground with a cardboard box with another child. The incident occurred 0n 11/25/2019 at 10:00 am where a child (C1) was playing with another child (C2) with a large cardboard box out in the playground. During today's inspection on 3/5/2020 at 11:35 AM, LPA interviewed Staff # 1 who was present during the incident. Staff stated they observed C1 and C2 playing with a cardboard box in the playground. C2 was dragging C1 through the makeshift tunnel by C1's right arm. Staff told C1 that he was going to get his clothes dirty and thought they were having fun given that C1 did not complain of anything hurting. S1 stated that 5 minutes later, C1 began to complain that his right arm was hurting and was unable to lift his arm without pain. The child began to cry and S1 took C1 to the Site Supervisor who immediately applied an ice pack to the child while at the same time contacting the child's parent. The parent came to pick up the child at 10:30 AM on the day of the incident to seek medical attention.

Continued on 809-C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Betzayra CervantesTELEPHONE: (805) 680-7175
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: CDR - RIO ROASLES HEAD START
FACILITY NUMBER: 566212166
VISIT DATE: 03/05/2020
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Site Supervisor stated that C1 was diagnosed with a dislocated right shoulder and placed in a sling for one week. C1 returned to the facility on 12/02/2019 with doctor's restrictions. C1 remained in a sling until 12/09/2019 and was placed on modified activities. During the incident, there were 13 children and 3 staff present on the playground. Site Supervisor stated that the children will no longer be using cardboard boxes to play with out in the playground as a precaution. Based on the information obtained from today's unannounced visit, staff interviews, LPA determined staff provided adequate supervision and took appropriate action.

No deficiencies were cited for this incident today.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Betzayra CervantesTELEPHONE: (805) 680-7175
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
LIC809 (FAS) - (06/04)
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