376701223-4-10-2023-20-CC-MMAE-CQS3WY-20230410183732

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376701223
Report Date: 04/10/2023
Date Signed: 04/10/2023 06:37:45 PM

Document Has Been Signed on 04/10/2023 06:37 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:	HAZEL GOES COOK ELEMENTARY SCHOOL		FACILITY NUMBER:	376701223
ADMINISTRATOR:	GABRIELA LLAMAS		FACILITY TYPE:	850
ADDRESS:	875 CUYAMACA AVENUE		TELEPHONE:	(619) 425-9600
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY: 48	TOTAL ENROLLED CHILDREN: 41	CENSUS: 19	DATE:	04/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jacqueline Ramirez		TIME COMPLETED:	11:20 AM

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	On 4/10/23, at 9:00am, Licensing Program Analyst (LPA) Martha Malane, conducted an unannounced annual inspection and met with Lead Teacher, Jaqueline Ramirez. LPA disclosed the purpose of the inspection and was led on a tour of the facility. This is an AM/PM half day program which operates on a traditional school year schedule. Days and hours of operation are Monday – Friday 8:00am-4:00pm. There were 21 children and four (4) staff members present. This is a Title IV Program. Furniture and equipment are in good condition. Playground equipment is in safe condition. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. Areas around high climbing equipment and slides have wood chips for cushioning material to absorb falls. Toilets and handwashing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors. Facility has a functioning carbon monoxide detector that met statutory requirements. Meals and snacks are provided by the school district. Lead teacher stated there are no bodies of water on the premises. Lead teacher stated there are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions and other hazardous items are made inaccessible. No poisons were observed during the inspection. All facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions through the Chula Vista Elementary School District. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility at off-site activities. The name of the child care center director or fully qualified teacher designated to act in the director’s absence was reported to the Department. See LIC809C continuation...

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

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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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: HAZEL GOES COOK ELEMENTARY SCHOOL	FACILITY NUMBER: 376701223
	VISIT DATE: 04/10/2023

NARRATIVE

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The person who signs the child in/out of the facility shall use their full legal signature and record the time of day. Children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than eight (8) children in care. LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment. LPA reviewed a sample of staff files and observed files for Staff 1 (S1) and Staff 2 (S2) did not have a current AB1207 Mandated Reporter training certificate; see LIC809D for deficiency cited.

This facility provides Incidental Medical Services (IMS). LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and director discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, Mandated Reporter Training, California Megan’s Law (www.meganslaw.ca.gov), Lead Poisoning Facts and Forms and Regulations.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, deficiencies were cited; see LIC809D page.

Exit interview conducted with Lead Teacher, Jacqueline Ramirez. This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

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.

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/10/2023 06:37 PM - It Cannot Be Edited

Created By: Martha Malane On 04/10/2023 at 10:44 AM

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: HAZEL GOES COOK ELEMENTARY SCHOOL	FACILITY NUMBER: 376701223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

(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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in two (2) out of four (4) staff did not have a current AB1207 mandated reporter training certificate on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Lead teacher stated she will work with Human Resources to ensure Staff 1 (S1) and Staff 2 (S2) complete the AB1207 mandated reporter training. Lead teacher stated she will submit the current certificates to the SDRO by 5/10/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Tulam Vu

LICENSING EVALUATOR NAME:

Martha Malane

LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC809 (FAS) - (06/04)

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