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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701118
Report Date: 04/20/2022
Date Signed: 04/20/2022 03:00:51 PM


Document Has Been Signed on 04/20/2022 03:00 PM - It Cannot Be Edited

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 EARLY HEAD START - WESTLAKEFACILITY NUMBER:
376701118
ADMINISTRATOR:LEILA EBTEKARIFACILITY TYPE:
830
ADDRESS:415 AUTUMN DRIVETELEPHONE:
(760) 631-2695
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:18CENSUS: 8DATE:
04/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Mayra ContrerasTIME COMPLETED:
03:15 PM
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On April 20, 2022 at 1:20 p.m. Licensing Program Analyst, Leilani Curtis, conducted an unannounced inspection to follow up on a self-reported incident that occurred on 4/7/22, wherein a child (C1) tripped walking down a step stool, fell and cut her lip and gums. LPA met with lead teacher Mayra Contreras and proceeded to tour the facility. There were 8 children with 3 staff members present. Appropriate ratio/capacity were observed. Staff members have the required background clearances and are associated to the facility.

LPA interviewed the lead teacher, staff #1 (S1) and staff #2 (S2). On 4/7/22 at approximately 10:20 a.m. C1 was walking down a two-step, step stool, in the restroom when she tripped and fell. C1 was holding the handrails of the step stool when the incident occurred. C1 hit her top lip and gums which began to bleed. S1 observed the incident and comforted the child. The child’s lip and mouth were cleaned, and ice was applied to the area. The parents of C1 were immediately notified and an incident report was completed and provided to the parents. C1 was taken to the dentist where no damage was found to the child’s teeth. At the time of the incident there were 3 children in the restroom being supervised by one staff member. Appropriate ratio/supervision was in place. The staff members responded appropriately, and the parent was notified timely. S1 and lead teacher Contreras state that the two-step, step stool will no longer be used. They also state that in the future when staff take children to the restroom a program aide or other staff member will accompany them to assist with the supervision of the children.

No deficiencies are cited

An exit interview was conducted with Ms. Contreras and appeal rights (LIC 9058 1/16) were discussed. Ms. Contreras's signature on this form acknowledges receipt of these rights. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed Ms. Contreras post notice of site visit.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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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