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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426205577
Report Date: 10/22/2024
Date Signed: 10/22/2024 01:35:52 PM

Document Has Been Signed on 10/22/2024 01:35 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:CAC - FILLMORE CENTERFACILITY NUMBER:
426205577
ADMINISTRATOR/
DIRECTOR:
SHONNA MARTINFACILITY TYPE:
850
ADDRESS:1316 E. OAK ST.TELEPHONE:
(805) 736-2811
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 30DATE:
10/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:38 AM
MET WITH:Shonna Martin and Cynthial HortonTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On 10/22/24 at 11:53 AM Licensing Program Analysts (LPAs) Elizabeth George and Susana Martinez conducted an unannounced Case Management- Incident Inspection. LPAs met with Director Shonna Martin & site supervisor Cynthial Horton and advised them the purpose of the inspection.LPAs were escorted through the facility inside and outside. During the inspection, LPAs observed 6 staff providing care to 30 children.

Incident reported on 10/21/24. On Friday Oct, 18. C1 was climbing up the curvy slide when she slipped and fell down the slide hitting her left elbow on the way down. Child came to school Monday morning with a cast on her left arm. Parents still don't know if it is broken or fractured. Child will need to see an orthopedic doctor. Site Supervisor stated she was approximately 6 -7 feet away from child when the incident happened. There were 3 teachers outside supervising 6 children at the time of the incident.

At arrival to facility LPAs observed that the play structure was taped/ boarded up and inaccessible to children in care. Director Shonna stated that due to the number of incidents that have occurred with the play structure she advocated to have the structure removed. It is to be removed from the facility on 10/28/24. Based on the information gathered during the inspection LPAs determined that the staff took appropriate action to meet the needs of the child #1 and other children in care.

During staff interviews it was disclosed that on Monday 10/21/24 there was another incident where a child threw a tin bucket filled with mud off the play structure resulting in an injury to a staff member who was located at the bottom of the structure assisting other children. An unusual incident report is in the process of being completed by the site supervisor. LPA determined staff took appropriate action to meet the needs of both children and staff.

cont. on 809-C
SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Elizabeth George
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: CAC - FILLMORE CENTER
FACILITY NUMBER: 426205577
VISIT DATE: 10/22/2024
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Upon arrival at facility, LPAs were unable to gain access to the facility due to the telephone lines being directed to Teams ( a cloud based phone service) and there being no one in the office answer the call. This service only works when someone is operating the computer. Missed calls are not recorded and the phones do not ring. LPAs discussed their concerns with this in the event that a parent needs to be in contact with the facility and there is no one in the office. A technical violation has been issued as a result of Title 22 Section 101224 not being met.

Appeal rights were given.

Exit interview conducted and report was reviewed with the Site Supervisor Cynthial Horton.

A notice of site visit was given and must be posted for 30 days.
SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Elizabeth George
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
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