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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 203801886
Report Date: 08/10/2021
Date Signed: 08/10/2021 01:25:00 PM

Document Has Been Signed on 08/10/2021 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:COTTONWOOD CREEK HEAD START CENTERFACILITY NUMBER:
203801886
ADMINISTRATOR:CARUSO, IRENEFACILITY TYPE:
850
ADDRESS:2236 TOZARTELEPHONE:
(559) 664-1109
CITY:MADERASTATE: CAZIP CODE:
93638
CAPACITY: 20TOTAL ENROLLED CHILDREN: 0CENSUS: 10DATE:
08/10/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Evelyn MoctezumaTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) conducted a case management inspection on this date. LPA met with site supervisor, Evelyn Moctezuma - Cruz. During today's inspection, LPA took a census, interviewed staff, took photographs of where the incident took place and reviewed a child's file.

LPA received an Unusual Incident Report. The incident took place on 8/4/21. Child #1 was climbing the rock climbing slide component on the licensee's climbing structure. Staff #2 was posted across the climbing slide, on or near the bike path. Staff #2 was helping a child on a tricycle. As staff #2 was turning to face the climbing structure, staff #2 observed child #1 falling face forward. Staff visual observation was from behind child #1. As the child was falling, staff #2 was running over to the child. Staff #2 was there before the child started crying. Staff #2 picked up the child and observed blood on the child's teeth. Staff #2 carried child to the grass area on the northern part of play yard. Staff #2 verbally alerted staff #1 who procured a first aid kit. Staff #2 put on gloves, applied pressure and then placed gauze over the cut bottom lip of child. The spacing between the cut sides was wide. Staff #3 called and informed father of child #1. Father arrived a the facility between 15 to 20 minutes. Staff #2 showed father where the incident took place. Father took the child #1 to Urgent Care. Child #1 received one stitch. Doctor's instruction was for child not to be in the sun and not to climb until stitch is removed. Per staff #2, the stitch will be removed this week. Child #1 was wearing plastic closed shoes. Father has decided that child #1 will be wearing tennis shoes instead of plastic closed shoes to ensure child does not slip when playing on the climbing structure.

Upon arriving at the center, LPA observed children playing outside. Child #1 was playing in the shade and wearing tennis shoes. Facility staff actions and followed up met the requirements for Title 22.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited. This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.
SUPERVISORS NAME: Michael Duarte
LICENSING EVALUATOR NAME: Cynthia Brannon
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2021
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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