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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426200008
Report Date: 05/22/2024
Date Signed: 05/22/2024 03:57:25 PM

Document Has Been Signed on 05/22/2024 03:57 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:CAC - ADAM CENTERFACILITY NUMBER:
426200008
ADMINISTRATOR/
DIRECTOR:		STACEY LARAFACILITY TYPE:
850
ADDRESS:500 W. WINDSOR ST.TELEPHONE:
(805) 925-6667
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 8DATE:
05/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Gabriela LanderosTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 5/22/2024, at 2:30 PM, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management inspection at the above Child Care Center to address the unusual incident report that occurred on March 8, 2024. Upon arrival, LPA met with Site Supervisor, Gabriela Landeros and explained the purpose of the inspection.

LPA and Site Supervisor toured the facility together. LPA observed 8 children and 4 staff present. LPA inspected the specific location of the incident which on March 8, 2024. During a soccer game, Child # 1 pushed and bit Child # 2 on the left shoulder after missing the ball and witnessing C2 gain the possession of the ball who was planning to hand the ball back to C1. The incident was observed by staff member Alicia Rodriguez.

Staff 2 immediately comforted C2 following the incident. Staff 2 provided an ice pack to C2 and remained with C2 until C2 was ready to play again. On the Other hand, Staff 1 spoke with Child # 1 about the incident, addressing the behavior. Parents of both children were notified by Site Supervisor, Stacey Lara

Continued on LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 - ADAM CENTER
FACILITY NUMBER: 426200008
VISIT DATE: 05/22/2024
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Later in the day of March 8, 2024, Child # 1 was observed to be agitated, To ensure the safety and well-being of C1 and other children, it was decided to temporarily remove C1 from the group setting to prevent any potential incidents of harm to C1 and other children and staff. The then Site Supervisor, Stacey Lara engaged with C1 and provide individual attention to help C1 process C1's emotion and calm down.

LPA reviewed the Behavior Intervention Plan (BIP) of C1 who receives continuous services. C1 has been under the BIP since the Early Head Start level.

No deficiencies were cited. Appeal Rights were given Notice of Site Visit was issued and must remain posted for 30 days.

Exit interview was conducted and report was reviewed with Site Supervisor , Gabriela Landeros.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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