566212889-12-3-2019-17-CC-FPEA-BJHS92-20191203124001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 566212889
Report Date: 12/03/2019
Date Signed: 12/03/2019 12:40:08 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:	CVUSD PRESCHOOL AT CITY CENTER		FACILITY NUMBER:	566212889
ADMINISTRATOR:	AMIE MILLS		FACILITY TYPE:	850
ADDRESS:	110 S. CONEJO SCHOOL RD.		TELEPHONE:	(805) 494-8100
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY:	104	CENSUS: 42	DATE:	12/03/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Bonnie Baruch		TIME COMPLETED:	12:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Frank Pedroza conducted an unannounced inspection for the purpose of conducting a Case Management. LPA met with facility Assistant Director Bonnie Baruch and discussed the purpose of the inspection. LPA and Assistant Director conducted a tour of the facility inside and out. On 11/13/2019, facility contacted Community Care Licensing (CCL) to self report an incident of a child sustaining an injury while in care. On 11/13/2019 at/or around 8:00 AM, a child (C1) was walking on some benches in the playground area. Teacher (T1) advised that the facility allows the children to only walk on the benches. According to T1, C1 started to run on the benches in a counter clockwise direction. Before T1 could tell C1 to stop running, T1 observed her slip and fall on the rubber wheel tires on the ground. T1 stated that the benches may have been slightly wet from the morning dew. When C1 fell on the tire, she went forward and hit her cheek on one of the benches. T1 went to assist C1 and saw that she had a cut below her right eye. Staff cleaned the area and provided a bandage for the cut. C1's mother was contacted and came to take her to the doctor. C1's cut required sutures. Continued on 809C

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019

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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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: CVUSD PRESCHOOL AT CITY CENTER	FACILITY NUMBER: 566212889
	VISIT DATE: 12/03/2019

NARRATIVE

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C1 returned back to the facility with a bandage covering her injury on 11/14/19. C1 was not given any restrictions that the facility had to address for her needs. The facility developed a suitable plan to address her needs while she had the sutures. LPA observed where the child had fallen. LPA advised that staff should check to see if the benches are wet prior to allowing children to walk/play on them. If the benches are wet to wipe the moisture off first or allow them ample time to dry. Given the facility's account of the incident when reporting it to CCL and how they addressed the incident, LPA deemed the facility's action was appropriate.

No deficiencies were cited during today's visit.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019

LIC809 (FAS) - (06/04)

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