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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364817504
Report Date: 01/21/2021
Date Signed: 01/21/2021 10:42:30 AM

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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:JUMPSTART, LEARNING CENTER, INC.FACILITY NUMBER:
364817504
ADMINISTRATOR:MIREYA GOMEZFACILITY TYPE:
840
ADDRESS:10213 BASELINE ROADTELEPHONE:
(909) 373-1831
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:28CENSUS: 8DATE:
01/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Mireya Gomez/DirectorTIME COMPLETED:
11:00 AM
NARRATIVE
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On 1/21/2021 at 10:08 AM, Licensing Program Analyst (LPA) Patricia Berry conducted a tele-inspection visit, via Face Time, due to COVID-19 and DPH guidelines of social distancing. The purpose of the tele-inspection visit was to conduct a case management- incident investigation. LPA made contact with the director, toured facility and took a census. On 1/15, LPA received a telephone call from assistant director (AD) stating a child drank bleach solution that was sprayed in a cup of water. AD stated on 1/14 child #2 came inside the classroom from outside play to get child #1 a cup of water. AD stated child #2 took a spray bottle filled with bleach solution (located on a counter) and sprayed some of the solution in child #1's cup. AD stated child #1 did drink a little of the bleach water. AD admitted the bleach bottle was accessible to the children. Teacher #2 admitted she did not lock up the bleach bottle solution before going on break. AD stated teacher #1 was standing at the back door observing children on the playground and observing child #2 in the classroom. Teacher #1 stated she was observing child #2 however, her attention was drawn to another child on the playground and did not observe the incident.

Regulation 101239 (g) states: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.
Regulation 101229(a)(1) states: Supervision shall include visual observation.

Deficiencies cited on 809D.

Director stated she took immediate action by notifying involved parents, and conducted staff training's.

LPA contacted the Director to review the report. This report will be sent via email to the provided email address with an attached read receipt. A copy of the LIC 9213- Notice of Site Visit, LIC 9058- Appeal Rights, LIC 9224- Acknowledgment of Receipt will be sent via email along with the report. The read receipt will be used in lieu of the signature on the report. All reports shall be maintained for three years.
(Cont on 809D)
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Patricia BerryTELEPHONE: (951) 782-4952
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: JUMPSTART, LEARNING CENTER, INC.
FACILITY NUMBER: 364817504
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/22/2021
Section Cited

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Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement was not met as evidenced by
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Based on assistant director and teacher #2 admission of culpability, the bleach solution was accessible to children in care.
This is an immediate risk to the Health and Safety of children in care.

Plan of correction discussed with director.
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send amended policy along with training and list to Community Care Licensing by 1/22/2021.
Type A
01/22/2021
Section Cited

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Responsibility for Providing Care and Supervision. (a)The licensee shall provide care and supervision as necessary... (1) Supervision shall include visual observation.


This requirement was not met as evidenced by
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Based on interviews conducted, teacher #1 did not see the incident occur.

This is an immediate risk to the health and safety of children in care.

Plan of correction discussed with director.
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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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Patricia BerryTELEPHONE: (951) 782-4952
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2