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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426207378
Report Date: 10/14/2025
Date Signed: 10/14/2025 02:33:51 PM

Document Has Been Signed on 10/14/2025 02:33 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 - CHESTNUT TODDLER CENTERFACILITY NUMBER:
426207378
ADMINISTRATOR/
DIRECTOR:		MARIA CERVANTESFACILITY TYPE:
850
ADDRESS:120 W. CHESTNUT AVE.TELEPHONE:
(805) 740-4555
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 9DATE:
10/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Shanno Martin TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 10/14/2025 Licensing Program Analyst (LPA) German Negrete made an unannounced visit for the purpose of conducting a Case Management – incident report. LPA met with Child Care Center (CCC) Program Manager Shanno Martin and discussed the purpose of the inspection. During today’s inspection, LPA did a walk through of the Child Care Center with Program Manager. At the time of the inspection there were 9 children and 4 staff providing care and supervision.

On 03/11/2025 Facility representative contacted Community Care Licensing (CCL) to self-report the following unusual incident : On 03/11/2025 at approximately 9:50am, 2 Teachers, S1 and S2, were supervising 4 children inside the classroom . S1 walked towards C1 and C2, who were standing next to each other at the dramatic play sink, reaching for the same toy, C2 quickly turned and scratched C1 on the right side of the cheek. S1 immediately went over to both children. S1 began comforting C1 and washed cheek area with water. S1 spoke to C2.

The second unusual incident was self reported on 7/29/2025 to Community Care Licensing (CCL): On 7/29/2025 at approximately 10:53am outside, S3, S4 and S5 were providing care and supervision to 8 children. Three teachers were zoned in various areas on playground observing the children play. C3 was observed by S3 running around the playground. Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Ana Tolentino
NAME OF LICENSING PROGRAM ANALYST: German Negrete
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: CAC - CHESTNUT TODDLER CENTER
FACILITY NUMBER: 426207378
VISIT DATE: 10/14/2025
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C3 tripped and lost coordination as C3 was running on trike path. C3 fell and bumped forehead on cement. S3 who observed incident went to C3 and assisted C3. S3 noticed a swollen bump on the right side of C3's forehead.

The written Unusual Incident Report (LIC624) that pertains to 3/11/2025 was received by the department on 03/18/2025. The second incident that occurred on 7/29/2025, the written LIC624 was received on 7/29/2025.

Today LPA conducted staff interviews, documented observations and reviewed documents (see LIC812).

The review of this incident revealed CCC staff notified parents of the three children who were involved in the aforementioned incidents in the appropriate time frame as outlined in Title 22 California Code of regulations. Also, according to program manager no medical attention was required for any of the children involved. This report marks the conclusion of the Unusual Incident review.



No citations issued today.

Exit interview was conducted, report reviewed, and copy was provided to CCC program manager Shanno Martin. Notice of site visit was provided.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

NAME OF LICENSING PROGRAM MANAGER: Ana Tolentino
NAME OF LICENSING PROGRAM ANALYST: German Negrete
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
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