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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421712405
Report Date: 11/10/2022
Date Signed: 11/10/2022 12:36:00 PM

Document Has Been Signed on 11/10/2022 12:36 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:GIRLS INCORPORATED OF CARPINTERIAFACILITY NUMBER:
421712405
ADMINISTRATOR:COLLINS, JAMIEFACILITY TYPE:
840
ADDRESS:5315 FOOTHILL ROADTELEPHONE:
(805) 684-6364
CITY:CARPINTERIASTATE: CAZIP CODE:
93013
CAPACITY: 100TOTAL ENROLLED CHILDREN: 100CENSUS: 0DATE:
11/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Jamie CollinsTIME COMPLETED:
12:44 PM
NARRATIVE
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On November 10th 2022 at 11:42AM, Licensing Program Analyst (LPA) Rosie Breault arrived at above stated facility to initiate a complaint investigation. LPA met with Assistant Director Jamie Collins. At the time of the inspection there were zero (0) children and (0) teachers present. In the front office, acting in the capacity of Executive Director’s assistant/support staff was Aja Forner. Also present was Darrell Brown in the capacity of Facility Administrator Specialist. Facility operates Monday, Tuesday, Thursday, and Fridays 2:30PM-5:30PM and Wednesdays 1:00PM-5:30PM

Upon LPA review of fingerprint clearance, both Ms. Forner and Mr. Brown have not been cleared to date.

Executive Director stated Ms. Forner has not been fingerprinted and was under the assumption that she did not have to due to her position at the facility. Executive Director stated Mr. Brown had been fingerprinted in 2021. LPA confirmed with Executive Director that they are paid staff members.

LPA advised assistant director all staff, volunteers, teachers etc. must be fingerprinted prior to commencing work at facility, and that both individuals may not work at facility until cleared.

Facility did not have two individuals fingerprinted and associated to the facility. This is a violation of California Code of Regulation, Title 22 Division 12 101170(e) (1). Type A deficiency and civil penalty assessed is being cited on the attached LIC 809D. LIC9224 provided and advised Executive Director of requirements.

Exit interview was conducted with Executive Director and appeal rights provided.

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Maryrose Breault
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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Document Has Been Signed on 11/10/2022 12:36 PM - It Cannot Be Edited


Created By: Maryrose Breault On 11/10/2022 at 12:09 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: GIRLS INCORPORATED OF CARPINTERIA
FACILITY NUMBER: 421712405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2022
Section Cited
CCR
101170(e)(1)

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Prior to working or volunteering in a licensed childcare facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.
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Executive director to submit LIC508, Request for LiveScan and proof of clearance for both individuals to LPA by Jan. 1 2023 via email: maryrose.breault@dss.ca.gov
Individuals are not to be on site until cleared.
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This evidence is met by:
Two (2) staff members have not been cleared to work in the facility.
(Aja Forner and Darrell Brown)
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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:Ana Tolentino
LICENSING EVALUATOR NAME:Maryrose Breault
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022


LIC809 (FAS) - (06/04)
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