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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376624050
Report Date: 05/26/2023
Date Signed: 05/26/2023 03:06:33 PM


Document Has Been Signed on 05/26/2023 03:06 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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108



FACILITY NAME:WONG, LUCILYN FAMILY CHILD CAREFACILITY NUMBER:
376624050
ADMINISTRATOR:LUCILYN WONGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 368-4854
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:14CENSUS: 9DATE:
05/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Lucilyn WongTIME COMPLETED:
03:20 PM
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On 5/26/2023, at 2:20 p.m., Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management inspection to follow up on a self - reported incident. LPA Williamson met with Licensee, Lucilyn Wong. LPA discussed the purpose of the inspection and toured the indoor and outdoor of the facility. Also present was Assistant, Judilyn Tuazon. There were 9 children present.

On 5/16/2023, the licensee self- reported an incident involving Child 1 (C1) sustaining an injury while in care that required medical attention. Per Licensee, the alleged incident occurred on 5/16/2023 at about 1:00 pm. Licensee stated that C1 was running, tripped and fell landing on the concrete edging surrounding the base of a tree in the front courtyard play area. There were 12 children present in the courtyard during the time of the incident.

LPA conducted interviews with the licensee, staff and the authorize representative of C1. LPA inspected the play area in the front courtyard where the incident occurred. LPA observed that licensee has placed safety coverings on the corners of the concrete edging surrounding the base of the tree. LPA did not observe any safety concerns. This incident was determined to be accidental.

No deficiencies cited. An exit interview was conducted with Licensee, Lucilyn Wong and a copy of this report, Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit is required to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
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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