Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566209597
Report Date: 11/05/2015
Date Signed 11/05/2015 01:14:16 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:CDR - JULIE IRVING HEAD START CENTERFACILITY NUMBER:
566209597
ADMINISTRATOR:ALICIA RAMIREZFACILITY TYPE:
850
ADDRESS:231 VENTURA BLVD.TELEPHONE:
(805) 485-7878
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:40CENSUS: 14DATE:
11/05/2015
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Renee Gonzalez and TIME COMPLETED:
01:17 PM
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LPA Marie Trujillo made an unannounced site visit for the purpose of conducting a Case Management visit to follow up on an incident involving a day care child that occurred on 8/20/15.

The purpose of the visit was discussed with Patricia Rivera, Family Services Specialist, as the Site Supervisor Rene Gonzalez was not present during the initial part of the visit but arrived later. Staff #1 who was present and observed the incident regarding child #1 was interviewed. On 8/20/15 at the time of the incident there were three staff present out in the playground. One of the staff was the assigned scanner. Child #1's file was reviewed, CDR Band Aid Report, CDR Health Services Report and doctor's report was reviewed and copies were obtained.

There is no indication child #1 sustained an injury while on the climbing structure due to failure to provide care and supervision by staff.

No deficiencies were cited.
SUPERVISOR'S NAME: Patricia S. GutierrezTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Marie TrujilloTELEPHONE: (805) 722-5138
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2015
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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