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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421702506
Report Date: 10/31/2022
Date Signed: 10/31/2022 01:58:48 PM

Document Has Been Signed on 10/31/2022 01:58 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:CAC - MAGGIE ESPINOZA CENTERFACILITY NUMBER:
421702506
ADMINISTRATOR:ELVA QUINTANILLAFACILITY TYPE:
850
ADDRESS:120 TOGNAZZINI STREETTELEPHONE:
(805) 343-1695
CITY:GUADALUPESTATE: CAZIP CODE:
93434
CAPACITY: 25TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
10/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cynthia A. JimenezTIME COMPLETED:
02:30 PM
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On October 31, 2022 @ 1:00 PM, LPA asked staff Pre- Screening questions related to COVID-19. staff responses to the Pre-screening questions suggest no COVID-19 exposure on site.

On 10/31/2022, Licensing Program Analyst (LPA) Martina Jimenez, conducted an unannounced Case Management inspection to follow up on the report of an Unusual Incident Report (UIR) received by the Department on 10/11/2022. A toddler (C1) tripped and hit their forehead on the edge of a wooden bench by the fence in the outdoor play area. C1 sustained a bump on the right side of the forehead.

LPA met with Cynthia A. Jimenez, Teacher, and explained the purpose of the inspection. LPA and Site Supervisor viewed the outdoor play where the wooden bench is located. LPA observed the wooden bench in the children's play area.

The teacher stated C1 returned to care on 10/12/2022 with no restrictions. teacher stated C1 has not prolonged issues related to the injuries. The teacher stated C1 is being shadowed daily to prevent future incidents.

Based on observations and the interview with the teacher it is determined neither the equipment at the CCC nor the actions of the CCC's staff contributed to C1's incident. LPA best categorized the incident as an accident.

There were no deficiencies cites at this time. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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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