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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426205725
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:53:38 PM

Document Has Been Signed on 06/02/2023 12:53 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:CAPSLO - BONITA MIGRANT AND SEASONAL HEAD STARTFACILITY NUMBER:
426205725
ADMINISTRATOR:A.RAMIREZ-BARRONFACILITY TYPE:
850
ADDRESS:4685 EAST 11TH STREETTELEPHONE:
(805) 343-0324
CITY:GUADALUPESTATE: CAZIP CODE:
93434
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 16DATE:
06/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Maria CamachoTIME COMPLETED:
01:05 PM
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On June 2, 2023 @ 9:14 AM, Licensing Program Analyst (LPA) Martina Jimenez, conducted an unannounced Case Management inspection to follow up on a report of an Unusual Incident Report (UIR) received by the Department on 5/26/2023.

LPA met with Maria Camacho, Site Supervisor, the purpose of the inspection was discussed. LPA tour the center, LPA observed six (6) toddlers, ten (10) and four (4) staff in care at the time of inspection.

On 5/30/2023, @ 9:04am, LPA spoke with Raelyn Mc Cormack, Provisional Teacher, and Maria Camacho, Site Supervisor, on the telephone in reference to the incident that occurred on 5/25/2023. The incident was found to have been appropriately handled by the center. The center will continue to monitor the behavior of the child, talking with staff, children and parents body awareness.

The following Technical Assistance of Title 22 Division 12 section 101226.3(a) has been issued.

Based on observations and the interview with the Site Supervisor and staff it is determined by LPA to be best categorized the incident as an accident.

There were no deficiencies cites at this time. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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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