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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334818026
Report Date: 02/14/2023
Date Signed: 02/14/2023 07:42:41 AM

Document Has Been Signed on 02/14/2023 07:42 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
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:KIDS COLLABORATE EARLY LEARNING CENTER, INC.FACILITY NUMBER:
334818026
ADMINISTRATOR:KELLY HERNANDEZFACILITY TYPE:
850
ADDRESS:36555 VAN GAALE LANETELEPHONE:
9519261600
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 144TOTAL ENROLLED CHILDREN: 172CENSUS: 11DATE:
02/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Teresa EspinozaTIME COMPLETED:
07:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) James Wilkerson arrived at this facility to follow-up on an Unusual Incident Report (UIR) that occurred on 02/02/23. On that date children were being transitioned from the big playground back into the classroom. A child became separated and was left unattended for what the facility stated was about four minutes outside on the playground. A staff member noticed that the headcount in the classroom wasn't correct and went out to the playground to retrieve the child. The playground is completely barricaded by a tall block wall and fence and the back of a commercial building that doesn't have any windows. The child didn't appear to be in any imminent danger as the surrounding playground was secure. This will result in a lack of supervision.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility for the next 12 months.

The Notice of Site Visit and Type A Deficiencies from today’s visit must be posted for 30 days. Failure to keep these posted for the entire 30 days will result in an immediate $100 civil penalty for each.

SEE LIC 809D for deficiency cited.

An exit interview was conducted, appeal rights discussed and will be provided along with form LIC 9224 (AB633), a Notice of Site Visit and a copy of this report.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: James Wilkerson
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2023
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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Document Has Been Signed on 02/14/2023 07:42 AM - It Cannot Be Edited


Created By: James Wilkerson On 02/14/2023 at 07:30 AM
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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: KIDS COLLABORATE EARLY LEARNING CENTER, INC.
FACILITY NUMBER: 334818026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2023
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision - (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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The facility agrees to conduct an in-staff training on supervision and submit a copy of a signed itinerary to Community Care Licensing by 02/15/23.
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This requirement was not met as evidenced by: A child was left alone in a playground while being transitioned back to the classroom. A staff member noticed the child missing (about four minutes) and brought the child back inside the classroom. This poses an immediate risk to the health and safety of the children.
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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:Carlos Martinez
LICENSING EVALUATOR NAME:James Wilkerson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023


LIC809 (FAS) - (06/04)
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