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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566214960
Report Date: 06/17/2019
Date Signed: 06/17/2019 04:21:41 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:CDI - SESPE CDCFACILITY NUMBER:
566214960
ADMINISTRATOR:MARIA MORENOFACILITY TYPE:
850
ADDRESS:425 ORCHARD ST.TELEPHONE:
(805) 524-5526
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY:72CENSUS: 27DATE:
06/17/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Yolanda Beltran-Lead TeacherTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Laura Villanueva made an unannounced visit to complete a Case Management-Incident to follow-up on an incident that occurred on 05/13/2019. At approximately 9:45 AM during outside play time a child was getting off a bike lost her balance and fell; hitting an elbow. The child landed on her bottom and right arm. Staff applied ice and contacted the parent at approximately 9:55 AM. After nap time approximately 2:30 PM, staff contacted parent again stating child was complaining about elbow. Approximately 3:42 PM mom picked up the child. On 05/14/2019, mom took child to doctor. Doctor determined the elbow was fractured. Child's arm was placed in a cast and returned to school on 5/20/19.The child attended for about 2 weeks then moved out of the area and no longer attends child care center.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Laura VillanuevaTELEPHONE: (805) 722-5138
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2019
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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