<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800939
Report Date: 05/11/2021
Date Signed: 05/11/2021 11:54:35 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CHARLEY BROWN CHILDREN'S CENTERFACILITY NUMBER:
370800939
ADMINISTRATOR:ELIZABETH CORTESEFACILITY TYPE:
850
ADDRESS:5921 JACKSON DRIVETELEPHONE:
(619) 463-5126
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:94CENSUS: 72DATE:
05/11/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Cassidy Justo, Facility RepresentativeTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On May 11, 2021 at 10:36 AM, Licensing Program Analyst (LPA), Marie Hernandez, conducted an unannounced Tele-Conference Case Management Inspection due to the COVID -19 State of Emergency via Facetime with the Facility Representative, Cassidy Justo. The facility self reported the incident to the Department. The facility reports that on 05/04/2021 at approximately 10:45 AM, during playtime in the outside play yard, child #1 turned around near the picnic style table and lost his balance. The child hit his chin on the table and bit down on his inner lip. The child sustained cuts to his chin and inner lip. The parent was contacted and took child to the doctor. The child received two stitches in his bottom lip. At time of incident, there was one teacher with twelve children.

LPA conducted several interviews with child #1 and the staff. The Representative stated child #1 returned to the facility on 05/10/2021 with no further incident. As per the interviews with child #1, he tripped on his own feet and the teacher stated she observed child #1 had tripped on his own feet and lost his balance. The child stated his teacher saw him fall and cleaned up his wound. The teacher stated she observed the incident and immediately tended to child’s needs. LPA conducted a virtual inspection of the play yard for health and safety and did not observe any tripping hazards or safety issues in the play yard during the inspection. As per the interviews with child #1 and the teacher, the incident was an accident. Child #1 tripped on his own feet. This concludes the incident review.

LPA Marie Hernandez explained the case management incident inspection report, and the Facility Representative stated it was understood. An exit interview was conducted, and a copy of the report was emailed to the Facility Representative. The Representative was advised that acknowledgement of the receipt of the report is to be received within 24 hours. NOTE on Facility Signature: SEE FILE FOR ACKNOWLEDGEMENT.
SUPERVISOR'S NAME: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Marie HernandezTELEPHONE: (619) 767-2244
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
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 1