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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700650
Report Date: 05/02/2019
Date Signed: 01/30/2020 07:44:08 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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:MAAC PROJECT - FALLBROOK HEAD START - INFANTFACILITY NUMBER:
376700650
ADMINISTRATOR:M'LINDA ROSOLFACILITY TYPE:
830
ADDRESS:405 WEST FALLBROOK STREETTELEPHONE:
(760) 723-4189
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:12CENSUS: DATE:
05/02/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:M'Linda RosolTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst, Patricia Berry and Marlene Wong, went to the facility.

A case management visit was being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 02/27/19. It indicates that Katia Siarorva, Area Manager, observed Child #1 in the restroom with no staff present. The two teachers were in the classroom and did not observe the child open the door.

Based on the information gathered, the following violations have been identified: 101229(a) - Responsibility for Providing Care and Supervision.

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

An exit interview was conducted with Ms. Rosol , appeal rights discussed, and a copy of this report was provided to the facility.

An exit interview was conducted with Ms. Woods, appeal rights discussed and provided along with a copy of this amended report on 01/30/20


This is an amended report from the original report on 05/02/19.
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: James WilkersonTELEPHONE: (951) 248-0229
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2020
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MAAC PROJECT - FALLBROOK HEAD START - INFANT
FACILITY NUMBER: 376700650
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2019
Section Cited

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Responsibility for Providing Care and Supervision for Infants

(a) In addition to Section 101229, the following shall apply: (!) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. Under no circumstances
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shall ANY infant be left unattended. The requirement was not as evidenced by Child #1 being in the restroom with no staff present. This poses an immediate risk to the Health and Safety of children in care.
THIS IS AN AMENDED LIC809D WITH THE CORRECT SECTION CITED.

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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: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: James WilkersonTELEPHONE: (951) 248-0229
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2020
LIC809 (FAS) - (06/04)
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