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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376625406
Report Date: 06/11/2019
Date Signed: 06/11/2019 11:33:11 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:GIL-CERVANTES, SANDRA FAMILY CHILD CAREFACILITY NUMBER:
376625406
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
06/11/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Sandra Gil-CervantesTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA )Selina Siao conducted an unannounced case management visit for the purpose to follow-up on an incident that occurred on 05/31/2019 at 11:25pm. A 4 years old drop in day care child sustained an injury on the back his head and required stitches. The incident was self reported to Community Care Licensing by the facility within a timely manner and a written report was received within the seven days requirement on 06/04/2019.

Information gathered indicates that two children were riding on a toy car inside the living room. The children were bumping into each other and when child #1's car got bumped, it pushed the car back into a metal magazine rack. Licensee was on the sofa in the living room when the incident occurred and she observed the incident. Licensee checked the injured area and applied pressure to the area. Child #1 parent was contacted immediately after the incident and the child was taken to the emergency room and obtained stitches to the open cut that is about an inch long. Based on information obtained, it appears that the incident was an accident. Licensee stated that in the future she will be sure the children do not play so rough with each other.

No citation issue.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
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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