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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700314
Report Date: 06/19/2019
Date Signed: 06/19/2019 02:02:36 PM

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:KIDS' CARE CLUB-INFANTFACILITY NUMBER:
376700314
ADMINISTRATOR:TOBI STEINERFACILITY TYPE:
830
ADDRESS:10414 CRAFTSMAN WAYTELEPHONE:
(858) 675-7000
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:20CENSUS: 12DATE:
06/19/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Tobi Steiner, DirectorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Hood completed an unannounced case management inspection for the purpose of delivering an amended report from an original report dated, 05/10/2019, due to deficiency. Director admitted she did not contact the Department within 24 hours or submit a LIC 624 -Unusual/Injury Incident Report within 7 days.

Deficiency cited during today's inspection. Director's (LIC 9058 01/16) rights were provided. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed Director post notice of site visit. LPA reviewed this report prior to obtaining her signature below
SUPERVISOR'S NAME: Jason GarayTELEPHONE: (559) 243-4588
LICENSING EVALUATOR NAME: Michelle HoodTELEPHONE: (619) 767-2241
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
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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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: KIDS' CARE CLUB-INFANT
FACILITY NUMBER: 376700314
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2019
Section Cited

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Reporting Requirements(d)Upon the occurrence...of any of the events...below, a report shall be made to the Department...within the...next working day and during...business hours. In addition, a written report...shall be submitted to the Department within seven days (1) Events reported shall include the... (B) Any injury to any child that requires medical treatment.
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This requirement is not met as evidenced by: Director admitted she did not contact the Department within 24 hours or submit an Incident Report within 7 days. Based on Director’s admission, it was determined that on 03/21/2019, C1’s parent informed facility staff that a subsequent medical assessment of C1 was conducted. Facility failed to report the incident once facility became aware that C1 required medical assessment. This poses a potential risk to children in care.

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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: Jason GarayTELEPHONE: (559) 243-4588
LICENSING EVALUATOR NAME: Michelle HoodTELEPHONE: (619) 767-2241
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2019
LIC809 (FAS) - (06/04)
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