<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700829
Report Date: 12/30/2019
Date Signed: 12/30/2019 02:18:54 PM

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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:DISCOVERY ISLE CHLD DEVELOPMENT CENTER-INFANTFACILITY NUMBER:
376700829
ADMINISTRATOR:GRIGGS, ASHLEYFACILITY TYPE:
830
ADDRESS:3791 OCEANIC WAYTELEPHONE:
(760) 845-5765
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:26CENSUS: 13DATE:
12/30/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amy Reimer- Assistant DirectorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A case management visit is 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 12/13/2019. It indicates that on December 6th 2019 around 8:00am Child #1's Authorized representative brought to the Assistant director's attention that Child #1 may have been fed with another child's bottle. An investigation conducted with facility staff and review of cameras confirmed that Staff #1 fed child#1 (formula-fed infant) with Child #2's bottle that contained Breastmilk.

Facility records were reviewed and an Interview was conducted with the assistant Director. Based on the information gathered, the following violations have been identified: 101427(c)..The infant shall be fed in accordance with the individual plan.

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

An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to facility staff.

SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Otsanya CameronTELEPHONE: (951) 970-1388
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: DISCOVERY ISLE CHLD DEVELOPMENT CENTER-INFANT
FACILITY NUMBER: 376700829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2019
Section Cited

1
2
3
4
5
6
7

101427(c) The infant shall be fed in accordance with the individual plan..

This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on interview with Assistant Director, Licensee did not ensure Infant's individual feeding plan was followed.

This poses a potential risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Otsanya CameronTELEPHONE: (951) 970-1388
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2