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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701138
Report Date: 01/11/2023
Date Signed: 01/11/2023 06:00:54 PM

Document Has Been Signed on 01/11/2023 06:00 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:DOT TO DOTFACILITY NUMBER:
376701138
ADMINISTRATOR:ADRIANA RIVERAFACILITY TYPE:
850
ADDRESS:12160 ALTA CARMEL COURTTELEPHONE:
(858) 485-1978
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 56TOTAL ENROLLED CHILDREN: 44CENSUS: 33DATE:
01/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH: Aleksandra Starosacheva & Mahzad IraniTIME COMPLETED:
06:10 PM
NARRATIVE
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On 01/11/2023 at 1:35PM, Licensing Program Analyst (LPA) Selina Siao conduct an annual inspection. Upon arrival, LPA met with staff Aleksandra Starosacheva aka Sasha and proceeded to tour the facility. Licensee Mahzad Irani arrived during the inspection. There were 33 children in care during nap time. The following ratios were observed Roots (A) class had 9 children napping supervised by teacher Hillary Clark, Stem class had 10 children napping supervised by teacher aide Karen Vargas, Roots (B) had 7 children napping supervised by teacher aide Sumra Khan and Sprouts class had 7 children napping supervised by teacher Taylor White. Facility is within staffing ratio. All required notices, forms and license were posted. Furniture and age appropriate equipment is in good condition. Rooms have adequate heating, lighting, ventilation and drinking water from an operational water fountain. Storage cubbies are readily available, and room accommodates class size. Napping equipment consists of cots/mats which are kept outside the classroom in a storage area. Bathrooms are maintained with operational toilets and faucets with appropriate temperature. Paper towels and toilet paper are available. Bathroom is lighted and has ventilation. Food service area consists of a kitchen which is clean and free of hazards. Menu is not posted. Adequate food is available for snacks and children brings their own lunch. Cleaning supplies are kept in a locked cabinet. Outdoor play area is a fenced playground and facility was advised to add more sand under the slide area. The monkey bars does not appear to be age appropriate for children ages 2 to Kindergarten and shall not be use until a certify playground inspector checks the playground. The climbing structures and slides are securely fixed to the ground. Area has a tarp and trees used for shade. Children brings their own water bottle to the playground and grounds are free of debris or potential hazards. LPA reviewed sign in and out, first aid supplies and reviewed medication policy and storage. Isolation area is the lobby area.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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 9
Document Has Been Signed on 01/11/2023 06:00 PM - It Cannot Be Edited


Created By: Selina Siao On 01/11/2023 at 04:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: DOT TO DOT
FACILITY NUMBER: 376701138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above 5 out of 7 staff member's does not have a valid online mandated child abuse training certificate. Staff members M.S, S.K, L.S,T.W, SS needs to complete the online mandated child abuse training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2023
Plan of Correction
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Facility will have the staff members complete the required online mandated child abuse training and will submit their certificates to LPA no later than 2/7/2023.
Type B
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above Two of the staff members fingerprints are not associated to the facility but they are associated to the licensee's other location which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2023
Plan of Correction
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LPA transfer the two staff members fingerprints to this facility during the inspection. Facility shall submit a written plan of correction to LPA on what she will do to ensure to avoid the repeat violation.
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:Monica Cuddy
LICENSING EVALUATOR NAME:Selina Siao
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/11/2023 06:00 PM - It Cannot Be Edited


Created By: Selina Siao On 01/11/2023 at 04:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: DOT TO DOT
FACILITY NUMBER: 376701138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 7 staff's records does not have their physician's report LIC503 available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2023
Plan of Correction
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Facility will have the two staff members go to the doctor and complete their physician's report.
Type B
Section Cited
CCR
101226(e)(2)
Health-Related Services
(2) All prescription and nonprescription medications shall be maintained with the child's name and shall be dated.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above two of the children's prescription medication does not have the label directions as prescribed by the child's physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2023
Plan of Correction
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Facility shall provide a written plan of correction on what they will do to ensure that they will comply with this regulation in the future.
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:Monica Cuddy
LICENSING EVALUATOR NAME:Selina Siao
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/11/2023 06:00 PM - It Cannot Be Edited


Created By: Selina Siao On 01/11/2023 at 04:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: DOT TO DOT
FACILITY NUMBER: 376701138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101212(b)
Reporting Requirements
(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in as Director Adriana Rutherford has been out on leave since the end of October. Licensee failed to report and submit the change of director packet to Licensing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2023
Plan of Correction
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Facility shall submit a written plan of correction to LPA on what she will do to ensure that she does not violate this regulation in the future no later than 1/12/2023.
Type B
Section Cited
HSC
1597.16(a)(1)
A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above as facility has not completed the drinking water lead testing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2023
Plan of Correction
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Licensee will contact a certify lead water test to schedule the test and will submit the required document to Licensing no later than 2/07/2023.
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:Monica Cuddy
LICENSING EVALUATOR NAME:Selina Siao
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: DOT TO DOT
FACILITY NUMBER: 376701138
VISIT DATE: 01/11/2023
NARRATIVE
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Personnel and client records were reviewed and reporting requirements was also reviewed. All personnel have required criminal record clearances or exemptions. LPA reviewed Emergency Disaster Plan and last fire drill was conducted on 10/27/2021. Facility has an operating carbon monoxide detector. Facility has at least one staff member that has a valid EMSA approved CPR/FA when children are in care.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Child Care Providers can now sign up for Quarterly Updates and PINS through the DSS website at https://cdss.ca.gov/inforesources/community-care-licensing/subscribe. LPA discussed California Megan's Law with provider and advised her to go on the website at www.meganslaw.ca.gov.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: DOT TO DOT
FACILITY NUMBER: 376701138
VISIT DATE: 01/11/2023
NARRATIVE
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Refer to the next page LIC 809D for deficiency citations. An exit interview was conducted, and appeal rights were provided.

A notice of site visit was given and must remain posted for 30 days. Failure to keep notice posted will result in a civil penalty of $100.00.

All unusual incident reports shall be submitted to Licensing office via email at SDIncidentReports@dss.ca.gov or via fax at (619)767-2203.

Exit interview conducted and report was reviewed with the licensee and facility representative.

SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
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