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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401702641
Report Date: 07/01/2025
Date Signed: 07/01/2025 02:29:03 PM

Document Has Been Signed on 07/01/2025 02:29 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:ORFALEA FAMILY & ASI CHILDREN'S CENTER RM # 133FACILITY NUMBER:
401702641
ADMINISTRATOR/
DIRECTOR:		ASHLEY SHOALSFACILITY TYPE:
850
ADDRESS:1 GRAND AVE RM#. #133TELEPHONE:
(805) 756-1267
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93407
CAPACITY: 96TOTAL ENROLLED CHILDREN: 96CENSUS: 27DATE:
07/01/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Ashley ShoalsTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 07/01/2025, at 1:35 PM, Licensing Program Analyst (LPA) Shane Loftus conducted an unannounced Case Management Inspection of the above-mentioned Child Care Center (CCC) to follow up on an Unusual Incident Report (UIR) received by the Department on 04/29/2025. LPA met with Ashley Shoals, Director of the CCC and explained the purpose of the inspection. LPA toured the interior and exterior of the CCC.

The UIR involved a child in care (C1) playing in yard five (5). C1 fell off a play structure (plastic cube attached to a slide) onto cushioned artificial turf. C1 hit her elbow on the turf and complained of discomfort. A Student Staff member (S1) witnessed and immediately attended to the incident. LPA notes The Head Teacher was also in yard 5 supervising other children. The Director were then notified. The Director notified the parents, who then took C1 to the doctor for a medical assessment. A second medical assessment was then sought for C1. The medical assessment revealed that C1 did not sustain a serious injury.

LPA discussed the UIR with the Director and viewed the location where the incident occurred. LPA notes the area where the incident occurred has appropriate cushioning in the form of artificial turf. LPA notes C1 only attends the CCC on Tuesdays and Thursdays. The incident occurred on Thursday, and the child returned to the CCC the following Tuesday. The Director informed LPA C1 is still enrolled in the CCC and C1 has not experienced any prolonged effects related to the incident.

No deficiencies are cited during today's inspection. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director, Ashley Shoals.

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Shane Loftus
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
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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