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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566214141
Report Date: 01/17/2025
Date Signed: 01/17/2025 04:55:12 PM

Document Has Been Signed on 01/17/2025 04:55 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:EASTER SEALS VENTURA CDCFACILITY NUMBER:
566214141
ADMINISTRATOR/
DIRECTOR:		CATHERINE RUTLEDGEFACILITY TYPE:
850
ADDRESS:10730 HENDERSON ROADTELEPHONE:
(805) 647-1141
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY: 122TOTAL ENROLLED CHILDREN: 122CENSUS: 93DATE:
01/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Misbah SaadTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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On 1/17/2025 Licensing Program Analyst (LPA) German Negrete made an unannounced visit for the purpose of conducting/closing a Case Management – incident inspection. LPA met with Center Director Misbah Saad and discussed the purpose of the visit. During today’s inspection, LPA did a walk through of the Child Care Center with Director.

At the time of the inspection there were 93 children and 17 staff providing care and supervision.

On 11/19/2024 Director contacted Community Care Licensing (CCL) to self-report the following unusual incident : On 11/18/2024 at 10:12AM during outdoor play, C1 was walking on the obstacle course when C1 lost balance and hit C1's head on a wooden log. It caused bleeding and abrasion to the right side of the forehead. 911 was contacted and C1's abrasion required stiches.

The Unusual Incident Report (LIC624) was received on 11/19/2024. Director followed reporting requirements as outlined in title 22.

During the course of the incident review, LPA conducted staff interviews and parent interviews. LPA conducted a facility file review. LPA conducted two facility inspections(see LIC812). LPA captured photos of the obstacle course(wooden logs) during a facility inspection conducted on 12/04/2024. Continued on LIC809-C

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: German Negrete
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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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: EASTER SEALS VENTURA CDC
FACILITY NUMBER: 566214141
VISIT DATE: 01/17/2025
NARRATIVE
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The staff interviews revealed and confirmed, C1 was in the play yard when the incident occurred. According to S1 and S2, and through name to face recognition document there were no more than 6 toddlers being supervised by S1 and S2. Also S1 and S2 confirmed C1 was on a obstacle course made up of wooden logs. C1 lost coordination a few times and fell. And in one of the moments when C1 fell, C1’s forehead impacted a wooden log. LPA confirmed Director contacted firs responders and the paramedics arrived to transport C1 to Ventura County Hospital.

LPA conducted a file review for incident reports in the last 12 months. There are no other incidents regarding play structure/ obstacle courses that were self reported to CCLD in the aforementioned time frame.

The parent interview revealed, that parent was contacted by the Director. However, due to a language barrier, the parent could not fully understand what had occurred. The parent also stated, parent met with S3 the day of the incident, S3 was able to show pictures of the obstacle course to parent . The parent mentioned that the obstacle course appeared to be made up of wooden logs. The parent continued to express concerns, stating that the particular obstacle course C1 was interacting with (the wooden logs) did not seem age-appropriate.

On 12/04/2024, LPA asked the director in person during a facility visit if the director could provide an instruction manual for the obstacle course. The Director stated that she would try to obtain the manufacturer's instructions and email them to LPA. Furthermore, LPA received manufacturer instructions via email on 01/17/2025. The manufacturer instructions do not include the wooden logs LPA observed and photo graphed on 12/04/2024. Continued On LIC812-C

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: German Negrete
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
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: EASTER SEALS VENTURA CDC
FACILITY NUMBER: 566214141
VISIT DATE: 01/17/2025
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LPA interviewed witnesses#1 and witnesses#2, both confirmed the wooden logs that LPA photographed on 12/04/2024 were part of the obstacle course the day C1 had the incident. Both witnesses stated they believe it was one of the wooden logs that caused the cut on C1's forehead(see LIC812).

Today a type B violation will be cited on LIC9099-D

Appeal rights were provided.

Notice of site visit was given at conclusion.


SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: German Negrete
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2025 04:55 PM - It Cannot Be Edited


Created By: German Negrete On 01/17/2025 at 12:09 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: EASTER SEALS VENTURA CDC
FACILITY NUMBER: 566214141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
101239(m)

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(m) All play equipment and materials used by children shall be age-appropriate.

record review, revealed this requirement was not met: On 11/18/2024 at 10:12AM during outdoor play, C1 was walking on the obstacle course when C1 lost C1's balance and hit C1's head on a wooden log.
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Director will sign a statment, confirming she understands the aformentioned regulation cited(fictures ,furnitures, equipment and supplies). Director will email the signed docuemnt to German.Negrete@dss.Ca.gov
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 It caused bleeding and abrasion the the right side of the forehead. 911 was contacted and C1's abrasion required stiches. Facility could not provide manufacturer instructions for all materials(wooden logs) that c1 interacted with the day of the incident.
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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:German Negrete
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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