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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619958
Report Date: 11/18/2021
Date Signed: 11/18/2021 01:18:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:PACIFIC CHILDREN'S CENTERFACILITY NUMBER:
343619958
ADMINISTRATOR:ALYSSA HALLFACILITY TYPE:
830
ADDRESS:6560 MELROSE DRIVETELEPHONE:
(916) 566-1600
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:25CENSUS: 9DATE:
11/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Alyssa HallTIME COMPLETED:
01:20 PM
NARRATIVE
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On Thursday, November 18, 2021 at 11:40 AM, Licensing Program Analysts (LPAs) Tanya Washington and Mikah Martinez met with Facility Representative Alyssa Hall regarding a self reported unusual incident which occurred on 11/12/2021. During today's inspection a tour of the facility was conducted, five napping toddlers were in care of one staff and four napping infants were in care of two staff. During the inspection Teacher on Special Assignment, Lena Sounders and Nicole Schlie, ECE Program Specialist arrived to the facility to assist with the visit.

Facility self reported that on November 12, 2021 around 11:30 AM, substitute Staff #1 gave Child #1 Q.T. Plus Hospital-grade disinfectant instead of water to drink. During the interviews with staff, LPAs learned that the cleaning solution was stored in a milk gallon which was located behind the children's eating area. The gallon had the name of the cleaning solution written in sharpie and Staff #1 did not pay close attention to the label. The substance of the cleaning solution is clear and appears as water.

Facility immediately contacted the school nurse, child's parent and Poison Control. Staff indicated that Staff #2 observed Child #1 spit out the cleaning product and it did not appear as Child #1 swallow any product. Poison Control advised to keep the child awake for at least one hour to watch for any signs of respiratory struggle. Staff indicated that the child was okay for the remainder of the day and was picked up at the regular pick up time.

Since the incident, janitorial services no longer deliver the cleaning solution in a milk gallon, the cleaning solution is also no longer left out on the counter. LPAs observed that the cleaning solution is stored in the upper kitchen cabinet with a safety label. Facility was also recommended to put bright tape over the cap to distinguish the look from regular water.
Continued on LIC809-C
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: PACIFIC CHILDREN'S CENTER
FACILITY NUMBER: 343619958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited

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The licensee shall ensure that each child is accorded the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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This requirement is not met as evidenced: Staff #1 mistakenly gave Child #1 hospital grade disinfect to drink instead of water. This is an immidiate risk to the health and safety of chidlren in care.
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delivered in a gallon which has a cleaning safety label.

This deficiency is cleared today.

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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: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: PACIFIC CHILDREN'S CENTER
FACILITY NUMBER: 343619958
VISIT DATE: 11/18/2021
NARRATIVE
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Title 22 deficiency is cited on the subsequent page of this report (LIC809D). Facility Representative acknowledges, that for TYPE A DEFICIENCIES ONLY upon receipt, Facility Representative shall post LIC809-D with Type A deficiency for 30 days 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 during the next 12 months. LIC9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the Facility Representative. This report was reviewed with Facility Representative, a notice of site visit is posted and appeal rights are provided.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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