376701430-10-12-2023-51-CC-GCUS-CWJN3X-20231012100703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376701430
Report Date: 10/12/2023
Date Signed: 10/12/2023 10:07:06 AM

Document Has Been Signed on 10/12/2023 10:07 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:	VILLAGE BLOOM CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	376701430
ADMINISTRATOR:	PAULINE ASCUE		FACILITY TYPE:	850
ADDRESS:	448 RANCHO SANTA FE ROAD		TELEPHONE:	(760) 704-8314
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY: 48	TOTAL ENROLLED CHILDREN: 48	CENSUS: 0	DATE:	10/12/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kendra DeGroot		TIME COMPLETED:	10:15 AM

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On October 12, 2023 at 9:00 a.m. Licensing Program Analyst’s (LPA’s), Leilani Curtis and Renita Rodriguez, conducted an unannounced inspection to follow up on a self-reported incident that occurred on 10/4/23, wherein a child (C1) injured her foot playing in the sand area of the playground. LPA's met with Co-Director Kendra DeGroot and proceeded to tour the facility. There were no children in care. The co-director states that they are conducting parent conferences today, 10/12/23, and tomorrow 10/13/23.

LPA’s interviewed Co-Director DeGroot. On 10/4/23 at approximately 10:00 a.m., C1 was observed playing with a small metal shovel in the sand area. C1 was not wearing her shoes when she accidentally cut her toe with the shovel. The children are allowed to decide whether they will wear shoes at the facility for developmental/sensory purposes. The co-director states that facility staff inspect the facility and playground prior to it's use. Facility staff elevated C1’s foot and applied a clean paper towel with pressure to the wound. The parent of C1 was contacted and picked up the child. The parent was given an incident report at the time of pick up. C1 was taken to the doctor where a “glue type bandage” was applied. At the time of the incident there were 12 children on the playground being supervised by two staff members. Appropriate ratio/supervision was in place. The staff members responded to the injury appropriately and reported timely. C1 has not returned to care due to unrelated reasons. LPA’s inspected the playground sand area. Ms. DeGroot states that the small metal shovels that the children played with have been removed and are no longer in use. LPA’s observed that the facility is now using light weight plastic shovel’s for the children to play with.

No deficiency cited.

An exit interview was conducted with Co-Director DeGroot and Appeal Rights (LIC 9058) were discussed. Ms. DeGroot’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’s observed Ms. DeGroot post notice of site visit.

SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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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