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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566215284
Report Date: 07/10/2026
Date Signed: 07/10/2026 01:46:03 PM

Document Has Been Signed on 07/10/2026 01:46 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:FUSD-MOUNTAIN VISTA PRE SCHOOLFACILITY NUMBER:
566215284
ADMINISTRATOR/
DIRECTOR:		LORENA RAMOSFACILITY TYPE:
850
ADDRESS:918 FIFTH STREETTELEPHONE:
(805) 524-6781
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 12DATE:
07/10/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Oliva LaraTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 07/10/26 at 1:00 PM, Licensing Program Analyst (LPA) Veronica Martinez and Nicole Ketterer conducted a Case Management–Incident inspection at the Child Care Center (CCC) to follow up on an Unusual Incident Report (UIR) received by the Department on 05/29/26. The reported incident involved a child in care (C1) who sustained an injury during outdoor play. According to the report, C1 was jumping near the child's play gazebo and struck their mouth on the structure, resulting in an injury that required medical attention and the removal of two teeth by a dentist.

LPA met with Site Supervisor Oliva Lara and explained the purpose of today's inspection. LPA observed 12 children and 3 staff present during the inspection.

LPA toured and observed the child's play gazebo area where the incident reportedly occurred. During the inspection, LPA assessed staff positioning and visibility of children within the outdoor play area. It was determined that staff positioned in the designated supervision areas would have a clear line of sight to children utilizing the child's play gazebo area.

The Site Supervisor stated that C1 sustained an injury to the mouth that required medical attention. The Site Supervisor reported that the center was operating within the required teacher-child-ratio at the time of the incident and that staff were actively supervising children during outdoor play. However, staff did not directly witness the moment when C1 struck their mouth on the gazebo structure. The reported ratio at the time of the incident was 2:24. The incident occurred at approximately 10:00 a.m., and the parents were notified immediately. Staff provided first aid by cleaning the injury and applying ice and pressure to the affected area. The parents transported C1 to a dentist, where C1's two front teeth were removed as a result of the injury.

LPA and the Site Supervisor discussed active supervision and staff monitoring of children during outdoor play activities. The Site Supervisor reported implementing additional measures to help prevent similar incidents from occurring in the future.

CONTINUATION LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Veronica Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2026
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: FUSD-MOUNTAIN VISTA PRE SCHOOL
FACILITY NUMBER: 566215284
VISIT DATE: 07/10/2026
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LPA investigated the incident through interviews conducted with the site supervisor. Based on information obtained, C1 was participating in outdoor play at the time of the incident. Staff reported they were supervising children in the area and responded immediately after becoming aware of the injury. Staff followed the center's procedures by administering first aid and notifying the parents without delay. Information gathered during interviews was consistent with the details documented in the Unusual Incident Report.

Following the incident, C1 continues to be enrolled and attend the Child Care Center.

Based on information obtained during the inspection and investigation, no Title 22 deficiencies were cited at this time.

An exit interview and review of the report were conducted with site supervisor Olive Lara. A Notice of Site Visit was provided and must remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Veronica Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC809 (FAS) - (06/04)
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