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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600031
Report Date: 04/29/2024
Date Signed: 04/29/2024 12:50:30 PM


Document Has Been Signed on 04/29/2024 12:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108



FACILITY NAME:CARMEL VALLEY PRESCHOOLFACILITY NUMBER:
376600031
ADMINISTRATOR:HOLLY SMITHFACILITY TYPE:
850
ADDRESS:13340 HAYFORD WAYTELEPHONE:
(858) 481-7933
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:125CENSUS: 96DATE:
04/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Holly Smith TIME COMPLETED:
01:15 PM
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 4/29/23 at 9:00 AM, LPA Annette Sutherland made an unannounced Case- Management deficiency visit. LPA met with Director Holly Smith. Due to facility that not reporting incidents that occurred on 2/21/24 & 4/15/24. Facility must report incidents within 24 hours of occurring via duty line and submit an Unusual Incident Report within 7 days.

It has come to the Department’s attention that there were incidents regarding inappropriate interaction between children on 2/21/24 4/15/24 that were not reported to Licensing, per regulation.

LPA explained unusual incident reporting (LIC 624) to Holly Smith and timeline.

See LIC809D for type B deficiency cited.

The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed Licensee post notice of site visit.
SUPERVISOR'S NAME: Joelle ReddingTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Annette SutherlandTELEPHONE: (619) 629-8751
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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


Document Has Been Signed on 04/29/2024 12:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108


FACILITY NAME: CARMEL VALLEY PRESCHOOL
FACILITY NUMBER: 376600031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2024
Section Cited
CCR
101212(d)

1
2
3
4
5
6
7
(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Director has provided correction on today's visit. She will ensure that in the future incidents are reported on the duty line (619)767-2248 and submit an incident report by email to SDIncidentReports@dss.ca.gov or by Fax at (619 767-2203 within 24 hours by phone and 7 days by mail/email of occurring.
Licensee will also provide written statement explaining that she will submit future reports per the required time frames.
8
9
10
11
12
13
14
This requirement was not met as evidenced by the department did not receive an incident report within 7 days.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Joelle ReddingTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Annette SutherlandTELEPHONE: (619) 629-8751
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2