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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566215336
Report Date: 11/12/2021
Date Signed: 11/12/2021 03:54:34 PM

Document Has Been Signed on 11/12/2021 03:54 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:FUSD - SAN CAYETANO PRE SCHOOLFACILITY NUMBER:
566215336
ADMINISTRATOR:ELVIA PARREIRAFACILITY TYPE:
850
ADDRESS:514 MOUNTAIN VIEW ST.TELEPHONE:
(805) 524-6040
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 17DATE:
11/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Lorena Ramos TIME COMPLETED:
04:08 PM
NARRATIVE
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On November 12, 2021 at 11:16 PM, Licensing Program Analysts (LPAs) Francisco Pedroza and Michael Mathew conducted an unannounced Case Management inspection. LPAs met with facility Site Supervisor Maria Barajas and advised her the purpose of the inspection. Site Supervisor provided LPAs a tour of the facility inside and out. There were 17 children in care at the time of the inspection.

On September 29, 2021, Director contacted Community Care Licensing (CCL) to report two incidents that occurred on September 29, 2021. Director advised a child was left unattended in the classroom for one (1) minute and a child was left unattended for one (1) minute in the restroom.

During the inspection LPAs conducted staff interviews about the incident. Staff advised during the interviews. that during one incident a staff escorted children to the restroom. Once the children lined up the staff escorted the children back to the classroom. The staff counted the children and realized they were one child short. They went back to the gate. The child was waiting at the restroom directly in front of the gate. During the second incident staff advised that they were escorting children out of the classroom to escort the children to the restroom. When they got to the bottom of the ramp, they observed that one of the children did not line up with them. The staff saw through the window that the child was still asleep. The other staff that was outside advised they will supervise the children that needed to use the restroom and escort them while the other staff return to the classroom to supervise the child sleeping. Per records the facility was not out of ratio during both incidents. Staff advised that each incident was about one (1) minute in occurrence.

Continued on 809-C
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Francisco Pedroza
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: FUSD - SAN CAYETANO PRE SCHOOL
FACILITY NUMBER: 566215336
VISIT DATE: 11/12/2021
NARRATIVE
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On November 12, 2021 at 3:20 PM, LPAs determined that there was a lack of supervision during both incidents. Staff interviews confirmed that they miscounted children initially. Director advised that she understood. LPAs advised California Code of Regulations, (Title 22, Division 12) 101229(a)(1) Responsibility for Providing Care and Supervision will be cited.

A closing interview was conducted with Director Lorena Ramos. Director was provided and advised of their right to appeal.

One type B deficiency was cited during today's inspection.

Notice of site visit posted.
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Francisco Pedroza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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Document Has Been Signed on 11/12/2021 03:54 PM - It Cannot Be Edited


Created By: Francisco Pedroza On 11/12/2021 at 03:24 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: FUSD - SAN CAYETANO PRE SCHOOL
FACILITY NUMBER: 566215336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2021
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision ... to meet the children's needs.
(1) No child(ren) shall be left without the supervision ... shall include visual observation.
This requirement was not met evidence by:
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Facility director will submit a written plan of correction (POC) stating measures to be taken in order to follow Title 22 Regulations and avoid another incident like this happening again. Director will provide POC to Community Care Licensing by 11/23/2021 via email, fax, or mail.
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Based on LPAs observations, interviews, and records. The facility had two (2) incidents resulting in a lack of supervision where children were left alone. This poses an potential Health and Safety risk to persons/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:George Mingle
LICENSING EVALUATOR NAME:Francisco Pedroza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021


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