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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401710383
Report Date: 04/09/2024
Date Signed: 04/09/2024 02:35:16 PM

Document Has Been Signed on 04/09/2024 02:35 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:ANDERSON FAMILY CHILD CAREFACILITY NUMBER:
401710383
ADMINISTRATOR/
DIRECTOR:		ANDERSON, JANETFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 466-0907
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
04/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Janet AndersonTIME VISIT/
INSPECTION COMPLETED:
11:31 AM
NARRATIVE
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On April 9, 2024 at 10:30 AM, Licensing Program Analysts,(LPAs) Gigi Reyes and Joaquin Mendez conducted an unannounced Case Management Inspection at the above Family Child Care Home. (FCCH) LPAs met with Licensee, Janet Anderson, Assistants, Mary Dyck and Mark Anderson. LPAs discussed the purpose of the inspection. There were 9 children present, playing outside under the supervision of 3 staff. Another child dropped off at the time of the inspection.

The licensee self reported to Community Care Licensing (CCL) that on 3/27/2024 while playing outside Child # 1 was riding a 3 wheel scooter and was rolling fast and accidentally hit the corner of the home. Child # 1 sustained an injury and received 7 stiches as the result of the accident.

According to the Licensee, she was outside with approximately 8 children in care when the incident occurred. Licensee immediately applied first aid and simultaneously contacted the parent who arrived at the FCCH around 5:00 PM.

Continued on LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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: ANDERSON FAMILY CHILD CARE
FACILITY NUMBER: 401710383
VISIT DATE: 04/09/2024
NARRATIVE
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During the interview, Licensee disclosed that child was not wearing a helmet, she stated that to her understanding, helmet is not required when the wheeled toy has training wheels. Based on LPAs' observation, the manufacturing label states that helmet is required when riding the scooter. Licensee stated that there have been no similar incidents involving bikes or other wheeled toys at the FCCH before this incident.

As safety measures, Licensee kept the scooters away. Licensee ensures that helmets are provided to children every time they use wheeled toys. The corner of the home will be padded with a rubber pad.

During today's inspection, deficiency was cited under Title 22 Division 12.

Appeal Rights was provided and explained. Notice of site visit was given to applicant, and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Janet Anderson.




Continued on LIC 809D
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/09/2024 02:35 PM - It Cannot Be Edited


Created By: Gigi Reyes On 04/09/2024 at 01:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: ANDERSON FAMILY CHILD CARE
FACILITY NUMBER: 401710383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
102423(a)(2)

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(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:
(2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirment is not met as evidenced by:
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Licensee agreed to submit the plan of correction no later thatn 4/19/2024. As safety measures, Licensee purchased additional helmets for children's use while riding the wheeled toy and place rubber padding in the corner of the home structure.
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On 3/27/2024, Child 1 sustained injury and received stiches while riding on a 3 wheel scooter without a helmet, despite the sccoter warning label to wear helmet, knee/elbow pad and wrist guard. This poses a potential risk to health and safety of children in care.
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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:Maria Mueller
LICENSING EVALUATOR NAME:Gigi Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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