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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426214390
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:06:53 PM

Document Has Been Signed on 03/10/2022 02:06 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:GASTELUM FCC AKA LITTLE LADY BUG DAYCAREFACILITY NUMBER:
426214390
ADMINISTRATOR:BLANCA GASTELUMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 455-3569
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
03/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Maria Lourdes GastelumTIME COMPLETED:
02:15 PM
NARRATIVE
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A case management inspection was conducted in conjunction with a complaint inspection to document the following type A deficiency which was observed during the inspection.

At approximately 12:50PM, LPA M. Breault observed child #1 sitting up on the cot during nap time, then observed staff #1 inappropriately handle child #1 by the right upper arm and push the child down on the cot. Child #1 did not appear to be injured. LPAs advised child #1 was inappropriately handled and staff cannot force a child onto the cot or to lay down.

The following Type “A” deficiency is being cited in accordance to Title 22 of the California Code of Regulations, Division 12. Please refer to LIC9099D for documentation of deficiency cited.

A copy of this report must be provided to the authorized representatives of all currently enrolled children and must also be provided to newly enrolled children for the next 12 months. The report shall be provided no later than the next business day or the next day the child is in care.

The ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) shall be signed and kept in each of the children’s records. Web site address to obtain forms, review quarterly updates, review Title 22 & Health & Safety Codes is: https://www.cdss.ca.gov/inforesources/child-care-licensing

Exit interview conducted with Licensee Maria Lourdes Gastelum.
SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Sylvia Mendoza-Ceja
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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Document Has Been Signed on 03/10/2022 02:06 PM - It Cannot Be Edited


Created By: Sylvia Mendoza-Ceja On 03/10/2022 at 12:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GASTELUM FCC AKA LITTLE LADY BUG DAYCARE
FACILITY NUMBER: 426214390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2022
Section Cited
CCR
101223(a)(3)

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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, ....
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Correct Immediately,
Submit a Plan of correction to Licensing for review by 03/16/2022
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This requirement was not met and evidenced by:
LPA's observation of staff #1 inappropriately handle child #1 by the right upper arm and push the child down on the cot. This poses an immediate risk to the Health and Safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ana Tolentino
LICENSING EVALUATOR NAME:Sylvia Mendoza-Ceja
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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