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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566214912
Report Date: 09/19/2019
Date Signed: 09/25/2019 04:36:23 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:ABC LEARNING PRESCHOOL & CHILDCAREFACILITY NUMBER:
566214912
ADMINISTRATOR:GRACE MONTEJANOFACILITY TYPE:
830
ADDRESS:333 E. HARVARD BLVD.TELEPHONE:
(805) 933-3333
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY:14CENSUS: 8DATE:
09/19/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Grace MontejanoTIME COMPLETED:
09:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Laura Villanueva made an announced visit in order to conclude an investigation into a complaint. A Case Management-Incident report is being created. t During the investigation, LPA observed that an LIC 624-Unusual Incident report was not completed and submitted to Community Care Licensing for a child(C1) that sustained an injury requiring medical attention. The child's (C1) parents gave a copy of the medical report to the center staff. The incident was not reported to the Department.

The center is being cited a type B deficiency on the attached LIC 9099D during today's visit California Code of Regulations, (Title 22, Division & Chapter number 1).
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Laura VillanuevaTELEPHONE: (805) 722-5138
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019
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: ABC LEARNING PRESCHOOL & CHILDCARE
FACILITY NUMBER: 566214912
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2019
Section Cited

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101212 (b) Reporting Requirements. A report shall be made to the department within 24 hours of the occurrence of any unusual incident as specified.
This requirement was not met as evidenced by:
A complaint investigation revealed that an incident of a child sustaining an injury that required medical attention was not reporter to the Department.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Laura VillanuevaTELEPHONE: (805) 722-5138
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2