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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561709946
Report Date: 01/21/2025
Date Signed: 01/21/2025 03:34:53 PM

Document Has Been Signed on 01/21/2025 03:34 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:CATALYST KIDS- MOUNDFACILITY NUMBER:
561709946
ADMINISTRATOR/
DIRECTOR:		DEBORAH DORFMANFACILITY TYPE:
840
ADDRESS:455 S. HILL RD.TELEPHONE:
(805) 650-8791
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 79TOTAL ENROLLED CHILDREN: 79CENSUS: 18DATE:
01/21/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:18 PM
MET WITH:Kalee PizaroTIME VISIT/
INSPECTION COMPLETED:
03:39 PM
NARRATIVE
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On 1/21/2025 Licensing Program Analyst (LPA) German Negrete made an unannounced visit for the purpose of conducting/closing a Case Management - Incident inspection. LPA met with site supervisor Kalee Pizaro and discussed the purpose of the inspection. During the case management inspection, LPA did a walk through of the Facility with site supervisor. At the time of the inspection LPA observed 18 children and 4 staff providing care and supervision.

On 12/18/2024 Site supervisor contacted Community Care Licensing (CCL) to self-report the following unusual incident : at approximately 3:15PM C1 was outside playing on the grass with other children. During outdoor play time, C1 tripped/slipped and hurt right palm(scraped) and the right thumb. S1 and S2 observed the child crying. S1 and S2 comforted C1. S2 observed C1's palm had a open cut on the bottom portion of the thumb. S1 and S2 took C1 inside and applied ice, washed the hand, and applied more ice. According S2, when the parent arrived to pick up C1, S2 notified the parent. C1 was taken to Ventura Orthopedics. According to Staff and parent, C1 received a fracture, and C1 is currently wearing a brace on the right hand. Site Supervisor stated, parent did not provide a doctor's note.

The date the facility submitted a written Unusual Incident Report (LIC624) is till unknown. However LPA was able to obtain the email the facility utilized for submitting the UIR. The email utilized is not a email that corresponds with the Santa Barbara regional office CCL.(cclpbarb@dss.ca.gov). Continued on LIC809-C

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: German Negrete
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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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: CATALYST KIDS- MOUND
FACILITY NUMBER: 561709946
VISIT DATE: 01/21/2025
NARRATIVE
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 On 1/14/2025 LPA reviewed records and children files(LIC857). LPA did not observe a incident report in C1's file.

LPA also conducted staff interviews (see LIC812). Additionally LPA conducted parent interview (See LIC812).

Due to C1's file missing a unusual incident report (12/18/2025). Facility will receive a technical violation. Due to facility not submitting a written unusal incident report(LIC624) through the appropriate channels of communication the facility will receive a type B violation.

The report was read to Site Supervisor,

Notice of site visit was provided to Site Supervisor.

Appeal Rights were also provided.

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: German Negrete
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2025 03:34 PM - It Cannot Be Edited


Created By: German Negrete On 01/21/2025 at 02:51 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: CATALYST KIDS- MOUND
FACILITY NUMBER: 561709946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
101212(d)(1)(B)

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d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) ... Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
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The site supervsior will read section 101212(d)(1)(B) of Title 22 CCR. Site Supervsior and Admisnitrator will signa statements . Also the statement will include Site Supervisor aknowledging the correct channel of communication pertaining to UIR's
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Due to record review, this requirement was not met as The facility to submitt a written unusal incident report(LIC624) through the appropriate channels of communication and with in the appropriate time frame.
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UnusualIncidentReportsDO17@dss.ca.gov

Site Supervsior will also provide the statements via email to LPA Negrete

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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:German Negrete
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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