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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566216610
Report Date: 10/16/2024
Date Signed: 10/17/2024 09:48:41 AM

Document Has Been Signed on 10/17/2024 09:48 AM - 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:PACIFIC CAMPS FAMILY RESOURCE,INC.FACILITY NUMBER:
566216610
ADMINISTRATOR/
DIRECTOR:		KENNETH HARLEYFACILITY TYPE:
860
ADDRESS:4050 MARKET STREETTELEPHONE:
(805) 654-0686
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 3DATE:
10/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Genenis D'andreaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On October 16, 2024, Licensing Program Analyst (LPA) German Negrete made an unannounced visit to conduct a Case Management – Deficiencies inspection. LPA met with Center Licensing Coordinator Genesis D’Andrade , and the purpose of the visit was discussed.

During the inspection, LPA conducted a walk through of the Child Care Center with Licensing Coordinator. At the time of the inspection, there were three children and three staff members present.

On July 30, 2024, the Licensing Coordinator contacted Community Care Licensing (CCL) to self-report an unusual incident. The incident, which occurred on July 22, 2024,involved Child 1 (C1) playing inside the center. When C1 was asked to follow directions, they ran out of the room into an unsupervised, fenced area. There were 15 children and three staff members present at the time of the incident. Staff Member 7 (S7) ran after C1 and raised their voice to get C1’s attention. Another staff member contacted C1’s parent during the incident.

The facility informed the Community Care Licensing Division (CCLD) officer of the day by telephone four business days after the incident. The Unusual Incident Report (LIC 624) was received on July 30, 2024. Continued on LIC809-C.
SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: German Negrete
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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: PACIFIC CAMPS FAMILY RESOURCE,INC.
FACILITY NUMBER: 566216610
VISIT DATE: 10/16/2024
NARRATIVE
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Furthermore Licensing coordinator contacted CCLD on 7/30/2024 to self report the following incident: during a field trip, C1 was having trouble with direction, C1 was hitting and kicking the seat on the bus once inside C1 was given direction and was having trouble following instructions from the staff members, when getting ready to leave C1 ran into the parking lot and the Consolers ran after C1, the ratio at the time was 19 children and 4 staff. The incident occurred on 7/25/2024. The facility contacted CCLD via telephone after more than 48 hours had passed.

LPA conducted a file review and conducted staff interviews, which revealed C1 was involved in multiple similar unusual incidents in the past 12 months. In the incident that occurred on 7/22/2024 and in the incident that occurred on 07/25/2024, the facility failed to follow reporting requirements outlined in Title 22 California Code of Regulations.

A Type B citation will be issued today.(see LIC809-D)


Exit interview was conducted, report reviewed, and copy was provided to Center Licensing coordinator. Notice of site visit was given.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

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

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2024 09:48 AM - It Cannot Be Edited


Created By: German Negrete On 10/16/2024 at 02:14 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: PACIFIC CAMPS FAMILY RESOURCE,INC.
FACILITY NUMBER: 566216610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2024
Section Cited
CCR
101212(d)(1)(c)

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(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.
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all fully qualified staff nned to read the afromentioned section inreporting requirments and email LPA Negrete, confirming they fully undertsand reporting requirments as outlined in title 22. The staff will emial a signed docuement.
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Based on observation and interview, the Licensee did not comply with the section cited above as the Child Care Center did not report two unusual incdents(7/22/2024) and (7/25/2024) with in the appropirate time frame as outlined in the section above.
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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: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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