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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406214424
Report Date: 06/12/2024
Date Signed: 06/12/2024 12:54:40 PM

Document Has Been Signed on 06/12/2024 12:54 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-NIPOMO HEAD STARTFACILITY NUMBER:
406214424
ADMINISTRATOR/
DIRECTOR:		A. RAMIREZ-BARRONFACILITY TYPE:
850
ADDRESS:291 THOMPSON ROADTELEPHONE:
(805) 544-4355
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 10DATE:
06/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Socorro CanoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 6/12/2024, at 10:30 AM Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management inspection at the above Child Care Center to address the unusual incidents that occurred on April 16, 17, 2024. Upon arrival, LPA met with Site Supervisor, Socorro Cano and explained the purpose of the inspection.

LPA and Site Supervisor toured the facility together. LPA observed 10 children and 4 staff present at the CCC. LPA’s interview with Staff # 1 revealed that on 4/16/2024, while children were playing with water table outside, C1 began throwing water at friends using a measuring cup toy. Despite repeated reminders from Staff #2 to stop throwing the water, Child #1(C1) threw the cup filled with water at Staff 2. The cup missed Staff 2 and hit Child # 2 (C2)on the head, According to Staff 1, the impact sounded hard but C2 did not cry. Staff # 1 immediately attended to C2 to comfort and check for any injury. C2 did not sustain any marks or injury. Another staff attended to C1 to communicate the inappropriate behavior.

On 4/17/2024, another incident occurred involving C1. While Child # 3 (C3) was sitting on a chair, C1 pushed C3 without apparent reason, causing C3 hit the head. No injury was sustained. Incident was witnessed by Staff #3 Parents were notified of the incidents.

Continued on LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: CAPSLO-NIPOMO HEAD START
FACILITY NUMBER: 406214424
VISIT DATE: 06/12/2024
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Both incidents involving C1 and two other children were addressed promptly by the staff. Appropriate actions were taken to ensure the safety and well-being of the children involved.

LPA interviewed the Site Supervisor, and it was discussed that incidents involving C1 is a usual occurrence which indicates a disruptive behavior of the child. According to the Site Supervisor, behavioral support services were offered to C1, however, the parent did not follow through, leading to the suspension of the plan on 5/10/2024. CCC on the other hand, created a positive behavioral plan for C1 which includes training teachers and providing them with goals and strategies to build on C1’s strengths and address behavior issues.

During today’s inspection, no deficiencies were cited.

Notice of Site Visit was issued.

Exit interview conducted and report was reviewed with Site Supervisor Susan Cano
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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