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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600033
Report Date: 10/22/2019
Date Signed: 10/22/2019 02:43:18 PM

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:SAY-KUMEYAAY EXTENDED DAY PROGRAMFACILITY NUMBER:
376600033
ADMINISTRATOR:BONE, CHASMFACILITY TYPE:
840
ADDRESS:6474 ANTIQUA BLVD.TELEPHONE:
(858) 627-9412
CITY:SAN DIEGOSTATE: CAZIP CODE:
92124
CAPACITY:75CENSUS: 63DATE:
10/22/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Chasm BoneTIME COMPLETED:
03:00 PM
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LPA Nancy Diaz conducted an unannounced case management inspection in reference to a self-reported incident involving a 6 year old child who was chasing a ball when he tripped and fell. This child landed on his right arm resulting to a fractured elbow.

LPA met with site director Chasm Bone. Observed present today were 63 school-age children with staff Julia Vasquez, Ashley Crump, Phyllis Huey & Thomas Teague. Children were engaged in various indoor activities. Snack served today consisted of Celery sticks with cream cheese and raisins.

Based on LPA's observations, it appears that the injury was the result of an accident. There was proper supervision at the time and it appears that there were no tripping hazard in the area where it happened. No deficiency will be cited for this incident as there does not appear to have been a violation of regulation
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Nancy DiazTELEPHONE: (619) 767-2207
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019
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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