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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700775
Report Date: 05/20/2019
Date Signed: 05/21/2019 02:54:23 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:MAAC PROJECT HEAD START CARLSBAD 1 - EUREKA PLACEFACILITY NUMBER:
376700775
ADMINISTRATOR:ARIANA AYAZIFACILITY TYPE:
850
ADDRESS:3368 EUREKA PLACETELEPHONE:
(760) 720-4378
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:82CENSUS: DATE:
05/20/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Director Ariana AyaziTIME COMPLETED:
12:30 PM
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THIS IS AN ELECTRONIC COPY OF A HANDWRITTEN REPORT

Licensing Program Analyst, Joelle Redding, made an unannounced visit for follow up on a self reported incident that occurred on 5/14/19 wherein a 5 year old child (Child #1) sustained a fractured arm from a fall on the playground.

LPA spoke with Staff #1 who observed the incident. She stated that Child #1 and Child #2 were coming off the slide and running in one direction while Child #3 and #4 were heading in their direction. Child #1 and #4 collided. Child #1 appeared to "fly in the air" and then landed on the cushioned area beside the slide with his elbow propped up on the slide. Staff #1 brought him to sit down while another staff member brought ice and his parent was called. Children #2, 3 and 4 were interviewed and their statements corroborated Staff #1's statement and the other children's statements. Staff #2, the child's regular teacher, stated that the children (#2-4) told her that same information when she spoke with them on the day of the incident. Apparently the collision occurred while both sets of children were playing tag. Director states that staff has been reminded of proper supervision on the playground and their is no more tag allowed.

There were two staff by the play structure where it occurred, another on the end near the entrance and one near the overhang area by the playhouse. The facility responded appropriately and reported timely. Ratios and supervision were in place. No hazards were noted.

No deficiencies are cited.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Joelle ReddingTELEPHONE: (619) 767-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019
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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