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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701260
Report Date: 04/15/2024
Date Signed: 04/15/2024 11:54:43 AM


Document Has Been Signed on 04/15/2024 11:54 AM - 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:COPLEY PRICE YMCA - FRANKLIN ELEMENTARYFACILITY NUMBER:
376701260
ADMINISTRATOR:BARBARA THOMASFACILITY TYPE:
840
ADDRESS:4481 COPELAND AVENUETELEPHONE:
(619) 344-3000
CITY:SAN DIEGOSTATE: CAZIP CODE:
92116
CAPACITY:56CENSUS: 0DATE:
04/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Flent AdleanTIME COMPLETED:
11:00 AM
NARRATIVE
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On April 15th, 2024, at 10 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted a case management inspection to follow-up on a self-reported incident that occurred on 03/28/2024. LPA advised Director Flent Adlean and Interim Site Supervisor Shanyce Samuelu of the meeting’s purpose and was granted facility entry. The facility serves school aged children. There were no children present; there were two (2) staff members present.

On 03/28/2024, Child 1 (C1) eloped from their classroom and was gone for about five (5) minutes. (See LIC 811 Confidential Names). Staff 1 (S1) stated on 03/28/2024 at 3:25 PM, they conducted a head count and observed C1 still in the room. S1 further said that at about 3:30 PM, the child was returned to the room by an unknown school staff member. S1 said they conducted another head count at 3:30 PM upon C1's return and observed all children in the room.



Based on staff interviews and record reviews, a Type A violation of California Code of Regulations, (Title 22, Division 12. Chapter 1), is being cited on the attached LIC 809D. LPA provided Director Adlean with a copy of Health & Safety Code Section 1597.58 – Civil Penalties; Regulations Setting Forth Appeal Procedures for Deficiencies. A civil penalty of $500 has been assessed. See Civil Penalty Assessment (LIC 421IM) for detailing information.

LPA Jo Ann Legaspi informed Director Adlean that this report dated (04/15/2024) documents one (1) Type A citation, which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care. Also, LPA Legaspi informed Director Adlean to provide a copy of this licensing report dated (04/15/2024) that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. LPA provided Director Adlean with one (1) blank LIC 9224 form.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
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: COPLEY PRICE YMCA - FRANKLIN ELEMENTARY
FACILITY NUMBER: 376701260
VISIT DATE: 04/15/2024
NARRATIVE
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A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with Director Adlean.

SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2024 11:54 AM - It Cannot Be Edited

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: COPLEY PRICE YMCA - FRANKLIN ELEMENTARY
FACILITY NUMBER: 376701260

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision – “ … No child ... shall be left without the supervision of a teacher at any time … Supervision shall include visual observation …”

This requirement is not met as evidenced by:
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The director states staff will be retrained on supervision issues. Director states they will provide the Department with a copy of the training curriculum and staff sign in sheet by 05/15/2024.
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Based on interviews, the Licensee did not comply with the section cited above in that a child was left without the visual supervision of a teacher, which poses as an immediate health, safety or personal rights risk to persons in care.
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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 VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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