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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701343
Report Date: 05/31/2022
Date Signed: 05/31/2022 05:46:25 PM


Document Has Been Signed on 05/31/2022 05:46 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:TEMPLE ADAT SHALOM INFANTFACILITY NUMBER:
376701343
ADMINISTRATOR:MARILYN MILNEFACILITY TYPE:
830
ADDRESS:15905 POMERADO ROADTELEPHONE:
(858) 451-1200
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:28CENSUS: 15DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Marilyn MilneTIME COMPLETED:
06:00 PM
NARRATIVE
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On May 31, 2022 at 12:35 p.m. Licensing Program Analyst (LPA) Leilani Curtis visited the facility to conduct an annual inspection. Upon arrival LPA met with director Marilyn Milne and proceeded to tour the facility. LPA provided the LIC 125, Entrance Checklist to the director. Also present were a total of 15 children with 9 staff members. Appropriate ratios and capacity were observed. Staff members have the required background clearances and are associated to the facility. No excluded individuals are present.

There are no bodies of water or weapons at this facility. The facility does not maintain an operational carbon monoxide detector. Toys are safe and do not have sharp points, edges or splinters, or made of small parts that can be pulled off. There is sufficient infant napping equipment. Infant changing tables have padded surfaces no less than one inch thick, covered with washable vinyl, and raised sides at least 3 inches high. The changing table is within reach of a sink. There are no walkers, bouncy seats, exersaucers or jumpers in the rooms. All infants including those napping in cribs are under visual observation at all times. Rooms have adequate heating, lighting, and ventilation. Solid waste storage vessels, including moveable bins, have tight-fitting covers on, and are in good repair. Disinfectants, hazardous items and medications are inaccessible to children through latches and locks. The infant indoor and outdoor activity space is physically separate from the space used by other day care children. Outdoor play area is fenced with sufficient material for cushioning. Area has canopies used for shade. Infant room has a refrigerator used for infant food storage which is properly labeled by child name and date. Drinking water is readily accessible inside and outside the classroom. Parents provide all meals and snacks. Admission agreement, emergency information and medical assessment forms were reviewed for some children. Individual Feeding and Needs and Services Plans were reviewed for some infants. The Infant Sleeping Plan was also reviewed for some infants. Nap documentation is maintained for children up to 12 months of age. The information included: infant’s name, date, time of each 15-minute check and initials of the person who conducted each check. Nap documentation was not maintained for the toddlers over 12 months of age.

SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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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Document Has Been Signed on 05/31/2022 05:46 PM - 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: TEMPLE ADAT SHALOM INFANT
FACILITY NUMBER: 376701343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and director interview, the licensee did not comply with the section cited above. The facility does not have an operational carbon monoxide detector on site. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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The director states that she will purchase and install a carbon monoxide detector. The director wil send LPA a video of the carbon monoxide detector operating via email by POC due date of 6/3/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/31/2022 05:46 PM - 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: TEMPLE ADAT SHALOM INFANT
FACILITY NUMBER: 376701343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101430(a)(3)(A)(4)(a)
Infant Care Activities
(A) Staff shall place infants up to 12-months of age on their backs for sleeping. (4) Infants with an Individual Infant Sleeping Plan [LIC 9227 (3/20)] that have Section C of the form completed and signed by an authorized representative shall be placed on their back when first laid down to sleep. In the event the infant changes position, the infant may remain in the alternative position. (a) Upon staff observation that the infant is capable of rolling from their back to their stomach and stomach to their back, the provider shall fill out Section D of the Individual Infant Sleeping Plan [LIC 9227 (3/20)], notify the authorized representative, and obtain the authorized representative's signature on the individual sleeping plan no later than the next business day following observation.

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 8 out of 10 Infant Sleep Plans, LIC9227, did not have section D completed advising the child's parent of the child's ability to roll over. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2022
Plan of Correction
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The director understands that section D of the Infant Sleep Plan is to be completed once facility staff observe a child roll from his/her back to his/her stomach and/or stomach to back. The director will have the LIC9227's completed and forward a copy of the completed documents to LPA via email by POC due date of 06/14/22.

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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/31/2022 05:46 PM - 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: TEMPLE ADAT SHALOM INFANT
FACILITY NUMBER: 376701343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 3 out of 10 staff members did not have verification of immunization against pertussis, measles or both. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2022
Plan of Correction
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The director states that she will send verification of immunizations for the 3 staff members to LPA via email by POC due date of 6/14/22.
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 in 6 out of 10 staff members do not have current mandated reporter certification. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2022
Plan of Correction
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The director states that she will have the 6 staff members complete mandated reporter training. The director states that whe will send LPA a copy of the completion certificates via email by POC due date of 6/14/22.

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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/31/2022 05:46 PM - 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: TEMPLE ADAT SHALOM INFANT
FACILITY NUMBER: 376701343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

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 4 out of 15 children were not signed into the facility by their parent or authorized representative. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2022
Plan of Correction
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The director states that she will send the parents/authorized representatives a letter advising them of the sign in/sign out requirements and have them sign an acknowledgement form. The director will send LPA a copy of the letter and signed acknowledgement froms via email by POC due date of 6/8/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
LIC809 (FAS) - (06/04)
Page: 3 of 8


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: TEMPLE ADAT SHALOM INFANT
FACILITY NUMBER: 376701343
VISIT DATE: 05/31/2022
NARRATIVE
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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.

Personnel records were reviewed for qualifications. Staff records contain documentation of education, training, and/or experience. Staff utilized as infant teachers have three child development units in infant/toddler care. Six of the 10 staff files reviewed did not contain current mandated reporter certification. Pediatric CPR/First Aid certifications were reviewed and are in compliance. Sign in/sign out sheets were reviewed. Four of 15 parents/authorized representatives did not sign their children into the facility. LPA reviewed the following with Director Milne: Updated Guidance For Child Care Providers Regarding Coronavirus Disease, PIN 22-10-CCP (dated 3/9/22), California Department of Public Health Guidance for Child Care Providers and Programs dated 3/12/22 and Recently Approved Safe Sleep Regulations in Effect, PIN 20-24-CCP. LPA obtained an updated Emergency Disaster Plan for Child Care Centers- LIC610A, Personnel Report-LIC500, Children’s Roster and Parent Handbook. The director will provide LPA with a copy of an updated Administrative Organization form, LIC309 by 6/17/22.

See LIC809D for cited deficiencies.

Child Care Providers can now sign up for Quarterly Updates and PINS through the DSS website. Please go to www.ccld.ca.gov and click on Child Care, go under Quick Links and Quarterly Updates, click on “Receive Important Updates” then enter your email address and choose which program(s) you would like to subscribe to and click “subscribe”.

Duty Officer: (619) 767- 2248, Monday thru Friday 8am-5pm.

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.

SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
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: TEMPLE ADAT SHALOM INFANT
FACILITY NUMBER: 376701343
VISIT DATE: 05/31/2022
NARRATIVE
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The director 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.

LPA discussed the safe sleep regulations with Director Milne and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director Milne.

SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC809 (FAS) - (06/04)
Page: 5 of 8