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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426205577
Report Date: 09/05/2024
Date Signed: 09/05/2024 03:45:09 PM


Document Has Been Signed on 09/05/2024 03:45 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 - FILLMORE CENTERFACILITY NUMBER:
426205577
ADMINISTRATOR:SHONNA MARTINFACILITY TYPE:
850
ADDRESS:1316 E. OAK ST.TELEPHONE:
(805) 736-2811
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:45CENSUS: 18DATE:
09/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Cynthia HortonTIME COMPLETED:
03:50 PM
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On September 5, 2024 Licensing Program Analysts (LPAs) Sylvia Mendoza-Ceja and Elizabeth George conducted an unannounced Case Management Inspection. LPAs met with Site Supervisor Cynthia Horton and advised her of the purpose of the inspection was to follow up on an incident reported to the Department on August 28, 2024 as required. LPAs were escorted through the facility inside and outside. During the inspection, LPAs observed 5 staff providing care to 18 children.

On August 28, 2024, at approximately 9:45 AM, child #1 was playing on the slide and lost her footing going down the slide and rolled down the slide. Child #1 cut the inside of the lip. Teacher #1 and Teacher #2 were supervising the children when the incident occurred. Teacher #1 observed the incident provided first aid to child #1. Parent of child #1 was called and sent a picture via the Learning Genie App. Child #1 sustained an injury requiring medical attention. At the time of the incident there were two teachers supervising 9 children on the playground. LPAs interviewed teacher #1 and teacher #2 regarding the incident.

Based on the information gathered during the inspection, LPAs determined that the staff took appropriate action to meet the needs of the child #1 and other children in care.

No deficiencies were cited as a result of the incident.

Exit interview conducted and report was reviewed with the Site Supervisor.

A notice of site visit was given.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0400
LICENSING EVALUATOR NAME: Sylvia CejaTELEPHONE: 805-562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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