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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700719
Report Date: 11/17/2021
Date Signed: 11/17/2021 01:48:29 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: 0DATE:
11/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Noemi RodriguezTIME COMPLETED:
02:00 PM
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On 11/17/2021 at 01:00 PM Licensing Program Analyst (LPA) Dana Stevens conducted a case management visit to follow-up on an Unusual incident that occurred 08/09/2021. Initial visit was conducted on 10/06/2021. LPA met with lead teacher Noemi Rodriguez and Director Dave Sheppard, and discussed the purpose of the visit. There were 0 children present at the time of the inspection.

The Unusual Incident was reported as follows: 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 beam. 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 made aware that Child #1 was injured later in the same day when informed by a phone call from Child #1's parent that Child #1 was taken to the pediatrician that afternoon. Staff #1 was provided medical documentation of the injury when parent returned the child to care on 08/11/2021. LIC 624 Unusual Incident Report was received timely by department on 08/12/2021. Director, Dave Sheppard, phoned in the verbal report of incident to the Duty line on 08/13/2021.

LPA previously inspected the playground equipment and appropriate padding is provided in the playground area. LPA discussed precautions used by staff to ensure children are safe while playing on the balance equipment. LPA also reviewed reporting requirements with staff. Telephone report was not timely, however the LIC 624, Unusual incident report was submitted to Community Care Licensing within the required reporting period. Exit interview conducted. Technical Violation issued on this date on the attached LIC9102tv. Copy of report and appeal rights were provided. 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: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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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