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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600751
Report Date: 06/21/2019
Date Signed: 06/21/2019 10:55:20 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:MERRY-GO-AROUND, THEFACILITY NUMBER:
376600751
ADMINISTRATOR:YVETTE JACKSONFACILITY TYPE:
850
ADDRESS:9175 KEARNY VILLA ROADTELEPHONE:
(858) 536-1008
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:72CENSUS: DATE:
06/21/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Yvette Jackson, Facility DirectorTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Marie Hernandez conducted the case management inspection due to an incident that occurred with a child sustaining an injury to the forehead. The facility reported that on 06/19/2019, a child tripped on another child's legs. The child sustained a wound to the forehead. However, the other child did not sustain any injury. The parent was contacted and took child to the doctor's. During the incident review today, LPA conducted interviews with the staff, child and parent. The teacher observed the incident that child tripped on another child's legs for no apparent reason. It was stated the facility staff handled the incident appropriately. The incident appears to be an accident.

No deficiency cited today. An exit interview was conducted and a copy of the report, along with the Notice of Site Visit was provided to the Facility Director. LPA observed the Director post the Notice of Site Visit in a prominent place. The Director states it is understood that this notice must be posted for 30 days.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2205
LICENSING EVALUATOR NAME: Marie HernandezTELEPHONE: (619) 767-2224
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
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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