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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421712022
Report Date: 03/06/2024
Date Signed: 08/22/2024 01:04:43 PM

Document Has Been Signed on 08/22/2024 01:04 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CAC - CUYAMA CENTERFACILITY NUMBER:
421712022
ADMINISTRATOR:KIM EICHERTFACILITY TYPE:
850
ADDRESS:2300 HIGHWAY 166TELEPHONE:
(661) 522-8813
CITY:CUYAMASTATE: CAZIP CODE:
93254
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 16DATE:
03/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Berta Zendejas Degodoy TIME COMPLETED:
11:30 AM
NARRATIVE
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On March 6, 2024, at 9:29 AM, Licensing Program Analysts (LPAs) Francisca Velazquez and Joaquin Mendez conducted an unannounced Case Management- Incident inspection. LPAs met with facility representative, Berta Zendejas Degodoy, Site Supervisor (S1) and advised her the purpose of the inspection. Facility representative and LPAs toured the facility inside and out. There were 16 children in care at the time of the inspection with three (3) teaching staff.

On February 2, 2024, Facility Representative, contacted Community Care Licensing (CCL) to report an incident that occurred on February 1, 2024, in which a child (C1) was found in the restroom with no supervision from an adult.

Facility representative interview revealed that 13 children had arrived on the bus on the morning of February 1, 2024. All children were escorted to the restroom by S1 and S2 for bathroom use and hand washing. S1 reported that one child was having a hard day and was attempting to run out of the restroom. S1 then decided to take 9 children to the daycare and left S2 with 4 children in the restroom. S2 reported that she helped the children wash their hands and then took 3 children to the daycare. About 2 minutes after arriving in the classroom, P3, C2 and C1 arrived at the daycare. P3 then informed S1 that C1 was found in the restroom alone. It was determined that C1 was alone in the restroom for about 2 minutes.

S1 contacted P1 to inform of the incident. S1 reports that C1 stayed at the CCC and was picked up at the usual time. S1 also reported that C1 continues to attend the CCC. Since the incident the facility had a training on active supervision. Additionally, the CCC has implemented a supervision tracking sheet to document the count of children during every transition. Interview with P1 confirmed the CCC informed P1 of the incident right away and reports that C1 is doing well and continues to attend the CCC.

CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CAC - CUYAMA CENTER
FACILITY NUMBER: 421712022
VISIT DATE: 03/06/2024
NARRATIVE
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During today’s inspection, LPAs determined that there was an Absence of Supervision as C1 was left unattended in the restroom. Staff interviews and statements confirmed that the CCC was not unaware that C1 was missing until C1 was escorted to the daycare by P3. Additionally, it was found that the CCC during this time was out of ratio as there was only one qualified staff with 13 children present.

Today, deficiency cited under Title 22 Division 12, Responsibility for Providing Care and Supervision (101229(a)(1) and Teacher-Child Ratio 101216.3(a). Appeal rights given. Upon receipt of this report, licensee shall post and provide copies of this licensing report to parents /guardian of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. Licensee to provide LIC 9224 for each child in care and have each parent sign the form that they have received a copy of the report.

A closing interview and review of report was conducted with Facility Representative, Berta Zendejas Degodoy. Notice of site visit and appeal rights were provided to Facility Representative.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
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Document Has Been Signed on 08/22/2024 01:04 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 03/06/2024 at 02:35 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: CAC - CUYAMA CENTER
FACILITY NUMBER: 421712022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2024
Section Cited
CCR
101229(a)(1)

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(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1)No child(ren) shall be left without the supervision of a teacher at any time... This requirement was not met as evidenced.
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Licensee agrees to submit a written statement detailing training and new supervision tracking sheet that documents all transitions during the day. This statement is due at the end of business on 3/7/24 via email to Francisca.Velazquez@dss.ca.gov
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Staff interview revealed that C1 was found alone in the restroom by P3. Staff confirmed they were not aware C1 was missing until C1 was escorted to the classroom by P3. This is an immediate risk to the health, safety and personal rights of children in care.
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Type A
03/07/2024
Section Cited
CCR101216.3(a)

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Teacher-Child Ratio: (a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below. This requirement was not met as evidenced. Staff interviews revealed S1 and S2 had 13 children when the bus arrived.
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Licensee agrees to submit a written statement detailing how the CCC will ensure that there are enough qualified staff for the number of children present and agrees to operate within the ratios. This statement is due at the end of business on 3/7/24 via email to Francisca.Velazquez@dss.ca.gov
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Interviews revealed S2 is not a qualified staff and cannot be left alone with children, therefore the CCC was out of ratio during this time. This is an immediate risk to the health, safety and personal rights 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:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


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