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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600778
Report Date: 12/07/2021
Date Signed: 12/08/2021 07:39:29 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:CLAIREMONT CANYONS ACADEMYFACILITY NUMBER:
376600778
ADMINISTRATOR:VICTORIA PETERSONFACILITY TYPE:
850
ADDRESS:6991 BALBOA AVENUETELEPHONE:
(858) 496-8400
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY:24CENSUS: 1DATE:
12/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Victoria Peterson, PrincipalTIME COMPLETED:
04:30 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 12/7/21 at 2:03 PM, Licensing Program Analysts (LPAs) Daniel Pena and Adrian Mangina conducted an unannounced Case Management visit. LPAs were greeted at the front of the facility by Principal, Victoria Peterson and granted entry after identifying themselves and disclosing the purpose of their visit. Observed present today was one child. There is one classroom (#31) currently designated for preschool use. Hours of Operation: 7:30 AM to 2:00 PM - Monday-Friday.

The visit was initiated due to a self reported incident involving child #1(C1). The licensee’s authorized representative, Principal Peterson self reported this incident by submitting form LIC 624 – Unusual Incident/Injury Report to Community Care Licensing (CCL), which was received in our office on 11/04/2021.

During today’s visit, LPAs conducted a brief tour of the center, obtained a copy of the facility roster, conducted interviews and reviewed child and staff records.

Based on today’s visit, no deficiencies were observed at this time. Exit interview conducted and report was reviewed with Principal Peterson. A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2214
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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