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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191503823
Report Date: 06/29/2023
Date Signed: 06/29/2023 12:59:50 PM


Document Has Been Signed on 06/29/2023 12:59 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:CAL POLY CHILD CARE CENTERFACILITY NUMBER:
191503823
ADMINISTRATOR:CELESTE SALINASFACILITY TYPE:
850
ADDRESS:3801 WEST TEMPLE AVETELEPHONE:
(909) 869-2284
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY:71CENSUS: DATE:
06/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Celeste Salinas, DirectorTIME COMPLETED:
01:20 PM
NARRATIVE
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On June 29, 2023, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced Case Management inspection at the above facility. A COVID-19 risk assessment was assessed prior to entering the facility. LPA met with director, Celeste Salinas who guided LPA on a tour of the facility. LPA observed 21 children in care with 12 staff members. The purpose of the inspection is to follow up on 2 incident reports that were reported to the department. The first incident occurred on 05/15/2023 and was reported to the department on 05/15/2023. The second incident report occurred on 05/18/2023 and was reported to the department on 05/19/2023. Both incidents were reported timely to the department.

Brief Summary: On 05/18/2023 at 11:40AM, Child #1 (C1) was playing out in the toddler yard. C1 was trying to climb up on a structure, as C1 was climbing a staff member (no longer working at the facility) told C1 to get down. C1 slipped and fell on the side of her head and one arm was behind her. C1 got up by herself and was crying. C1 sustained a broken left arm.

During this inspection, LPA interviewed Staff #1 (S1), Staff #2 (S2), obtained a copy of internal incident report, sign in sheets for children that were present in C1's classroom the day of the incident and a copy of the facility roster. LPA spoke with C1's mother (Parent #1 (P1)) who stated that C1 sustained a broken elbow and required surgery.

Based on interviews with S1 and S2, C1 was climbing the Tic Tac Toe portion of the climbing structure when S1 started to tell C1 not to climb the structure. C1 had started to being climbing when she fell and landed on her head with her arm bending. Per S1 and S2, C1 stood up and started to cry but was able to walk and was coherent. S1 called P1 to notify her of the incident that had occurred. C1 was given an ice pack and waiting for P1 on a cot where S1 sat next to C1 continuing to assess C1. LPA reviewed sign in sheets for children and staff that were in attendance the day of the incident; LPA observed there were 6 children and 3 staff members in the classroom/outside.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CAL POLY CHILD CARE CENTER
FACILITY NUMBER: 191503823
VISIT DATE: 06/29/2023
NARRATIVE
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There are no deficiencies being cited for the first incident as this was an incident that occurred fast and was unable to be prevented. Per S1 he witnessed the incident occur and took the proper measures to ensure C1 received the proper first aid care.

For the incident that occurred on 05/15/2023, LPA interviewed Child #2 (C2), Staff #4 (S4), attempted to interview Child #3 (child did not qualify) and attempted to interview Staff #3 (S3) but LPA was unable to leave a voicemail due to mailbox being full.

Brief Summary: On 05/15/2023, the HR director called regarding an investigation of S3. Another staff member was concerned that S3 while redirecting C3 by pulling C3's hand in a rough manner. C2 was having a hard time during nap time and S3 had child bouncing on cot to release energy.

Based on interviews conducted, C2 stated that S3 would grab and squeeze his arm when C2 was not following directions. When LPA asked C2 about bouncing on the cot with S3, C2 stated, "yeah she squeezed my hand".

The facility is being cited a Type B deficiency in accordance with Title 22 Regulations, please see LIC809D.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Celeste Salinas, Appeal rights explained & provided.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/29/2023 12:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: CAL POLY CHILD CARE CENTER
FACILITY NUMBER: 191503823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
101223(d)(3)

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Personal Rights: The licensee shall ensure that each child is accorded the following personal rights: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to:
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Director will hold a staff meeting reviewing personal rights with staff. Director will provide LPA with agenda of meeting and sign in sheet of staff that attended.
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interference with functions of daily living including eating, sleeping or toileting... This requirement was not met as evidence by: Based interviewes C2 stated that S3 would grab and squeeze his arm when c2 was not following directions. This poses a potential health and safety risk to 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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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