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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274410781
Report Date: 06/27/2019
Date Signed: 06/27/2019 02:09:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CSUMB CHILD DEVELOPMENT CENTERFACILITY NUMBER:
274410781
ADMINISTRATOR:JENNIFER SEBOLINOFACILITY TYPE:
850
ADDRESS:100 CAMPUS CENTER BLD #91TELEPHONE:
(831) 582-4550
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY:36CENSUS: 23DATE:
06/27/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jennifer SebolinoTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Joe Macias, conducted an unannounced case management visit in response to an unusual incident that the facility self reported to Community Care Licensing (CCL). LPA met with Jennifer Sebolino, site supervisor, and explained the nature of today's visit to her.

This visit was made to inquire about an unusual incident that occurred on June 6, 2019.

During today's visit LPA Macias interviewed the Site Supervisor, reviewed facility files, and obtained copies of pertinent information. Based on staff interviews, as well as the self reported incident report; a child's personal rights were violated when a staff member used the restroom in front of the child, in the children's restroom. The facility responded appropriately by reporting to CCL, and contacting the child's parents. The employee is no longer employed at the center.

As a result of this visit, a deficiency was cited.

Appeal right were printed and reviewed with the staff.

Type B deficiencies cited, exit interview conducted, and a copy of this report was provided to the facility.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Joseph MaciasTELEPHONE: (408) 334-8320
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2019
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CSUMB CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 274410781
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2019
Section Cited
CCR
101223(a)(1)
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Personal Rights. The licensee shall ensure that each child is accorded the following personal rights: To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidenced by: staff member used the restroom in front of the child, in the children's restroom.
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Director shall forward a written plan of correction to LPA by 07/12/2019 due date to indicate that a child's personal right shall not be violated; and that each child shall be treated with dignity in his/her relationships with staff and other persons. Director and staffs shall complete a training on personal rights and submit proof
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This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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of training to CCL by the POC date 07/12/2019
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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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Joseph MaciasTELEPHONE: (408) 334-8320
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2019
LIC809 (FAS) - (06/04)
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