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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600768
Report Date: 06/19/2023
Date Signed: 06/29/2023 05:00:16 PM


Document Has Been Signed on 06/29/2023 05:00 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108



FACILITY NAME:CONGREGATION BETH ISRAEL/SID RUBIN PRESCHOOLFACILITY NUMBER:
376600768
ADMINISTRATOR:CATHY GOLDBERGFACILITY TYPE:
850
ADDRESS:9001 TOWNE CENTRE DRIVETELEPHONE:
(858) 900-2530
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:105CENSUS: 45DATE:
06/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Director Cathy GoldbergTIME COMPLETED:
05:40 PM
NARRATIVE
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On 6/19/2023 @ 4:30 p.m., Licensing Program Analyst (LPA) made an unannounced visit to follow up on an self reported incident that was relayed to Director on 6/14/23.

Director submitted an LIC 624 stating that she was made aware that Staff #1 stepped away from a unsecured preschool child on the changing table on two occasions. LPA interviewed Staff #2 who witnessed the incidents.

Based on the information relayed, a Type B deficiency will be cited on the accompanying LIC 809D.

NOTICE OF SITE VISIT WAS GIVEN AND WILL REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Renesha AskewTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Joelle ReddingTELEPHONE: (619) 767-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
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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Document Has Been Signed on 06/29/2023 05:00 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108


FACILITY NAME: CONGREGATION BETH ISRAEL/SID RUBIN PRESCHOOL
FACILITY NUMBER: 376600768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2023
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision...The licensee shall provide care and supervision as necessary to meet the children's needs...No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation. This requirement was not met as evidenced by:
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Director states that she was made aware of the incident on the second occasion which occurred approximately one week ago. The prior was approximately two weeks ago. Immediately upon learning of the incident, she spoke with all staff about proper supervision on the changing table and posted the rules at
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Based on interview with Director and Staff #2, Staff #1 stepped away from a preschool child on the changing table, for approximately 10 seconds, on twodifferent occasions. This is a potential hazard to the health and safety of children in care.
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every changing table in the faciltiy. A copy was provided for LPA at this visit. She will ensure that staff adhere to this policy and there will be a reminder at staff meetings or more often, if needed.


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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: Renesha AskewTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Joelle ReddingTELEPHONE: (619) 767-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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