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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700314
Report Date: 11/08/2023
Date Signed: 11/08/2023 05:03:41 PM


Document Has Been Signed on 11/08/2023 05:03 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
SAN DIEGO N. CC RO, 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:
11/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Katherine Benns aka BarnesTIME COMPLETED:
05:10 PM
NARRATIVE
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On 11/08/2023 at 3:50pm, Licensing Program Analysts (LPAs) Selina Siao and Martha Avila conducted an unannounced case management inspection to follow up on a self-reported incident that happened on October 18, 2023. LPAs met with Assistant Director Katherine Benns and conducted a tour of the infant room. There were 12 infants supervised by staff members Arezoo Bakhtiiari, Mikayla Barker and Sanchaeta Chaka Borty. Appropriate ratio was observed, and all staff members have the required background clearances and are associated to the facility.

On 10/18/2023, one of the staff members witnessed another staff (S1) removed the infant bottle screw ring with the nipple off the bottle and poured the milk directly into a six-month-old infant's mouth while the infant was crying. The incident was reported to the Director on 10/19/2023 but the facility failed to report the unusual incident to the Licensing Department within the required 24 hours. The incident was reported to licensing on 10/27/2023.

See LIC809D for type B citation issue:
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
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 2


Document Has Been Signed on 11/08/2023 05:03 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
SAN DIEGO N. CC RO, 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: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2023
Section Cited
CCR
101212(d)(1)(C)

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Reporting Requirements
Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours ... Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
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Assistant Director stated the facility has created a spread sheet that the Director can record any concerns that are brought to her attention for follow up. Facility representative stated that they will go over the reporting requirement regulation and the unusual incident
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This requirement is not met as evidence by: On 10/18/2023, one of the staff member removed the infant bottle screw ring with nipple and poured milk into an infant's mouth while the infant was crying. The unusual incident was not reported to licensing until 10/25/2023. This poses a potential health and safety risk to children in care.
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form LIC624 with staff members. A copy of the agenda along with staff members sign in sheet will be submit to licensing no later han 11/17/2023.

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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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2