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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215771
Report Date: 05/14/2025
Date Signed: 05/14/2025 09:54:20 AM

Document Has Been Signed on 05/14/2025 09:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CAPSLO - SLO EARLY EDUCATION & CHILD CAREFACILITY NUMBER:
406215771
ADMINISTRATOR/
DIRECTOR:		A. RAMIREZ-BARRONFACILITY TYPE:
850
ADDRESS:981 MARSH STREETTELEPHONE:
(805) 544-4355
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 7DATE:
05/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Bre IversonTIME VISIT/
INSPECTION COMPLETED:
10:10 AM
NARRATIVE
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On 05/14/2025, Licensing Program Analyst (LPA) Shane Loftus conducted an unannounced Case Management inspection of the above-mentioned Child Care Center (CCC), to follow up on an Unusual Incident Report (UIR) received by the Department on 04/07/2025. Specifically, a child in care (C1) had an allergic reaction after consuming SunButter. LPA met with CCC Site Supervisor Bre Iverson and the Provisional Teacher who witnessed the incident. LPA explained the nature of the inspection. LPA notes 7 children are on site along with 5 teachers providing care and supervision.

During snack time on 04/07/2025, C1 was served SunButter (a peanut butter alternative) and graham crackers. After snack time, staff noticed that C1 was scratching her hand and when checked closely, C1 had skin irritation and redness on her hands. C1’s mother was arriving to the CCC during the incident and promptly administered Benadryl to reduce the allergic reaction. LPA notes C1 is allergic to peanut butter, eggs, dairy, tree nuts, and other things. LPA reviewed the child’s records to verify C1’s allergies were properly documented. LPA also verified that C1’s medication is properly stored and not expired. LPA’s interview revealed that C1’s diet/allergy forms were checked prior to snack distribution and the food served was believed to be safe. Staff confirmed this is the first time the child had an allergic reaction to SunButter, as it was a previously approved peanut butter alternative. LPA verified that C1’s diet/allergy forms have been updated appropriately. LPA notes C1 is still enrolled in the CCC and has no prolonged issues related to the injury.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Shane Loftus
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: CAPSLO - SLO EARLY EDUCATION & CHILD CARE
FACILITY NUMBER: 406215771
VISIT DATE: 05/14/2025
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Based on records review and the interview with the Provisional Teacher, LPA notes the staff followed C1’s dietary plan and could not have foreseen the allergic reaction. Additionally, CCC staff has taken the appropriate steps to update C1’s dietary plan to avoid a future allergic reactions.

No deficiencies were cited during today’s inspection. A notice of site visit was given and must remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Shane Loftus
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC809 (FAS) - (06/04)
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