Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406214335
Report Date: 10/09/2017
Date Signed 10/09/2017 05:26:25 PM

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:NIPOMO RECREATION-LITTLE BITS PRESCHOOL & TODDLERFACILITY NUMBER:
406214335
ADMINISTRATOR:NANCY MAROHNFACILITY TYPE:
850
ADDRESS:112 ORCHARD ROADTELEPHONE:
(805) 929-5437
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:60CENSUS: 12DATE:
10/09/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:13 PM
MET WITH:Nancy MarohnTIME COMPLETED:
05:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Martina Jimenez (LPA) conducted a case management visit regarding an incident which occurred at the facility on 09/06/2017 at around 4:30 pM. Licensee did submit a LIC 624 Incident report in the required time period. Licensee also contacted the officer on duty at the Goleta child care office to report the incident the following day.

The following was stated by the staff of what occurred:

Licensee stated there were 15 children and 3 staff in the facility on 09/06/2017. Child #1 received an injury while in care. None of the staff observed the incident when it occurred. The child #1's injury was treated and parents were notified.

Child #1 was later received medical treatment due to the incident that occurred on 09/06/2017. Child #1 returned to day care on 9/8/2017 with no restrictions or limitations.

Upon receipt of this report, licensee shall post for 30 days and provide copies of this licensing report to parents /guardian of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. Licensee to provide LIC 9224 for each child in care and have each parent sign the form that they have received a copy of the report LIC809 and LIC 809 D.

THIS REPORT MUST BE FILED IN FACILITY FILE AND MADE AVAILABLE FOR PUBLIC REVIEW FOR 3 YEARS.



Today, deficiency cited under Title 22 Division 12. Appeal rights given to the Director
LPA observed Director post the Notice of Site visit.
SUPERVISOR'S NAME: Deborah AjaoTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: NIPOMO RECREATION-LITTLE BITS PRESCHOOL & TODDLER
FACILITY NUMBER: 406214335
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2017
Section Cited
CCR
101229(a)(1)
1
2
3
4
5
6
7
Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).

On 9/6/17 a child received an injury while on the play yard. without staff knowledge

1
2
3
4
5
6
7
Licensee will submit a POC on how No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time.

Licensee is to provide a copy of this report to each parent/legal guardian of
8
9
10
11
12
13
14
Staff knowledge the injury when children were in line to come into the center from snack. The incident occurred between 3:45 PM and 4:30 PM
8
9
10
11
12
13
14
every child for the next 12 months. Every parent/guardian must sign a LIC 9224 , "Acknowledgment of Licensing Reports" and place a copy of this document in each child's file for the next 12 months.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Deborah AjaoTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2017
LIC809 (FAS) - (06/04)
Page: 2 of 2