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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700417
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:35:32 PM


Document Has Been Signed on 01/06/2023 02:35 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:SKYLINE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
376700417
ADMINISTRATOR:JACQUELINE SERRANOFACILITY TYPE:
830
ADDRESS:11330 CAMPO ROADTELEPHONE:
(619) 415-5485
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:45CENSUS: 22DATE:
01/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rosa Johnson and Jacqueline SerranoTIME COMPLETED:
02:50 PM
NARRATIVE
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On 1/6/2023 at 10:15am, Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management inspection to follow up on a self reported incident report. Upon arrival, LPA Williamson met with Rosa Johnson, Assistant Director. LPA discussed the purpose of the inspection and proceeded to tour the facility. There were five (5) infants in Room 301 with two (2) staff, eight (8) infants in Room 306 with two (2) staff. LPA observed nine (9) infants and three (3) staff from Room 316 entering the building and returning from a walk. The facility operates Monday – Friday 7:00am – 5:30pm. Director Jacqueline Serrano arrived during the inspection.

On 12/19/2022, the director self reported an incident of a possible personal rights violation that allegedly occurred on 12/13/2022.

On 12/13/2022, Staff 1(S1) and Staff 2 (S2) were providing bottle feedings for the infants in room 301 between 8:00 am and 8:32 am. S1 put the breast milk bottle for Child 1 (C1 ) into the bottle warmer and while waiting continued to assist other infants who were in the highchairs with their feedings. S2 who was assisting in the classroom, picked up Child 2 (C2) for their feeding, reaching into the bottle warmer to retrieve a breast milk bottle. S2 proceeded with the feeding, and fed C2 approximately three ounces of breast milk that belonged to C1.

Staff 3 (S3) reported to the classroom to relieve S1 for a break. S1 reviewed the infant board and determined that C1 was due for a feeding. S3 went to the refrigerator and noticed that C1's breast milk bottle labeled #1 was missing. S3 advised S2 to stop feeding C2 and observed that there was one ounce remaining in the bottle. S3 observed that the rubber label that was initially attached to C1's breast milk bottle which included C1's name and the date was at the bottom of the warmer. This resulted in C2 being fed the breast milk bottle belonging to C1. The parents of C1 and C2 were notified immediately and there was no medical attention required.

SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: SKYLINE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 376700417
VISIT DATE: 01/06/2023
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Interviews were conducted with the director, assistant director, staff and daycare parents. Based on evidence obtained, it was determined that the facility staff violated the personal rights of C2.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency is being cited, see LIC809 D.



Per Director, an investigation was conducted and S1 was reprimanded. Director has conducted training with staff and implemented bottle feeding procedures in the infant classrooms.

A Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days. LPA observed the Director post the Notice of Site Visit. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted with Director Jacqueline Serrano. Licensee/Appeal Rights (LIC9058) along with a copy of this report was provided to Director and their signature on this form confirms receipt of these rights.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/06/2023 02:35 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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108


FACILITY NAME: SKYLINE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 376700417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited

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101223(a) (2) Personal Rights. (a)The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... to meet his/her needs. This requirement is not met as evidenced by: Based on interviews and
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Director has agreed to conduct a training with staff regarding personal rights and feeding procedures in the infant classrooms. Director will provide a summary of the training and a copy of the staff sign in sheet to LPA, no later than 1/20/2023.
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record review, licensee did not comply with the above regulation as S1 and S2 violated
the personal rights of one (1) out of five (5) infants by feeding C2 the breast milk bottle of C1, which poses a potential health, safety or personal rights risk to persons 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: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
LIC809 (FAS) - (06/04)
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