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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700719
Report Date: 10/06/2021
Date Signed: 10/06/2021 07:07:17 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:VIP VILLAGE STATE PRESCHOOL AT NICOLOFF ELEMENTARYFACILITY NUMBER:
376700719
ADMINISTRATOR:EVELIN MEDINAFACILITY TYPE:
850
ADDRESS:1777 HOWARD AVENUETELEPHONE:
(619) 628-8690
CITY:SAN YSIDROSTATE: CAZIP CODE:
92173
CAPACITY:48CENSUS: 16DATE:
10/06/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Dave SheppardTIME COMPLETED:
04:40 PM
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On 10/06/2021, Licensing Program Analyst (LPA) Dana Stevens conducted a case management inspection to follow-up on an Unusual Incident that occurred on 08/09/2021 and was reported on 08/12/2021. LPA met with teacher Claudia Ramos and Director Dave Sheppard and discussed the purpose of the visit. LPA toured the facility, specifically the playground. Pictures were taken. Present were 16 children in class 37 P.M. session along with 3 staff members and 1 child present with 2 staff in class 36 PM session.

On 08/09/2021 during AM session, 14 children and 2 staff were present on the playground. Child #1 sustained an injury while playing on the balance steps. Staff #1 was nearby assisting the children however did not witness the child fall. Child#1 did not show signs of injury and did not inform any staff members at the time of the fall. Staff #1 was first made aware of the injury the evening of 08/09/2021 when parent of Child#1 called to inform her that Child#1 was injured while playing on the playground that day and that child will be taken to pediatrician. Later the same day parent of Child #1 informed Staff#1 that pediatrician recommended Child #1 be kept home one day. Child #1 returned to school on 08/11/2021. Director, Dave Sheppard, phoned in the verbal report of incident to the Duty line on 08/13/2021.

Copy of the medical report and diagram of playground and incident was obtained. Child files were reviewed and Director was interviewed. LPA inspected the playground equipment, as well as other equipment used in the classroom. Appropriate padding is provided in the playground area.

Exit interview conducted with Director. Additional information is necessary in order to complete this follow-up. Notice of Site Visit must be posted for 30 days.

SUPERVISOR'S NAME: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Dana StevensTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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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