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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700376
Report Date: 06/13/2019
Date Signed: 06/13/2019 06:55:45 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:CENTER FOR CHILDREN & FAMILIES AT CAL STATE SMSFACILITY NUMBER:
376700376
ADMINISTRATOR:LETISIA FORDFACILITY TYPE:
850
ADDRESS:453 LA MOREE ROADTELEPHONE:
(760) 750-8750
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY:144CENSUS: 5DATE:
06/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:55 AM
MET WITH:Stephanie Puhl/Program SpecialistTIME COMPLETED:
07:05 AM
NARRATIVE
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A case management visit is being conducted by Licensing Program Analyst (LPA) James Wilkerson in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 05/31/19. It indicates that a child had wandered out of a classroom as other children were entering through an open door. Another staff member in the next classroom noticed the child outside on the playground unattended and without any adult supervision. This is a zero tolerance violation and the citation will be accompanied by a civil penalty of $500.00.

See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility for the next 12 months.

The Notice of Site Visit and Type A Deficiencies from today’s visit must be posted for 30 days. Failure to keep these posted for the entire 30 days will result in an immediate $100 civil penalty for each.

See LIC 809C.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: James WilkersonTELEPHONE: (951) 218-7031
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CENTER FOR CHILDREN & FAMILIES AT CAL STATE SMS
FACILITY NUMBER: 376700376
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2019
Section Cited
CCR
101229(a)(1)
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Responsibility for Providing Care and Supervision . The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual
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Ms. Puhl agrees to have Director, Letisia Ford submit a written itinerary for training staff on supervision, with staff signatures to Community Care Licensing by end of business on 06/14/19.
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observation. This requirement was not met as evidenced by: An Uusual Incident Report stating that a child had left a classroom through an open door while children were entering the classroom. The child was found on the playground unattended and without adult supervision.
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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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: James WilkersonTELEPHONE: (951) 218-7031
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: CENTER FOR CHILDREN & FAMILIES AT CAL STATE SMS
FACILITY NUMBER: 376700376
VISIT DATE: 06/13/2019
NARRATIVE
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A Civil Penalty has been assessed on this visit. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

An exit interview was conducted, appeal rights discussed and provided on this date along with a copy of form LIC 9224 (AB 633) and a copy of this report on this date.

A copy of this report must be made available to the public, upon request for three years.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: James WilkersonTELEPHONE: (951) 218-7031
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3