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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330900976
Report Date: 01/06/2022
Date Signed: 08/30/2022 10:41:16 AM

Document Has Been Signed on 08/30/2022 10:41 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:TOWN AND COUNTRY DAY SCHOOLFACILITY NUMBER:
330900976
ADMINISTRATOR:BETTY BASHFACILITY TYPE:
850
ADDRESS:3614 PEDLEY AVENUETELEPHONE:
(951) 737-2130
CITY:NORCOSTATE: CAZIP CODE:
92860
CAPACITY: 85TOTAL ENROLLED CHILDREN: 85CENSUS: 50DATE:
01/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Betty Bash (Executive Director), Carla Reyes (Director), Kevin Bash (co-licensee)TIME COMPLETED:
05:00 PM
NARRATIVE
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***********************AMENDED REPORT****************************************
Licensing Program Analysts (LPAs) Kay Phillips and Blanca Ruiz conducted and inspection at the facility to follow up on an incident learned during an investigation of complaint 09-CC-20211203111317. Legal guardian(s) of the child involved are aware of the incident.

During the inspection, it was learned that Child# 1 stuck a pom-pom up his/her left nostril. This occurred while staff was working on a craft project for open house inside classroom #3. Per information disclosed by staff at the facility, emergency services were called to the facility site by the child's representative to check on child’s well-being after being contacted by the facility due to the incident. Per staff's disclosure, the child’s left nostril was obstructed by a cotton made pom-pom, approximately the size of a pea. Pertinent parties indicated medical attention was required to extract the object from the child's nose. Child returned to school the following day.

Per documents reviewed at the facility, the child's nose was obstructed for approximately 2-3 hours prior to adequate medical attention being sought.

Facility staff discussed the incident with director and action was taken to make sure adequate and active supervision is provided during craft activities. Staff did not report the incident to licensing within the 24 hours of the occurrence and seek medical attention for the child.
The following deficiencies were cited:

PLEASE SEE LIC-809-D
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Karrene Turner
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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 08/30/2022 10:40 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/19/2022 03:06 PM


Created By: Karrene Turner On 01/06/2022 at 10:29 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: TOWN AND COUNTRY DAY SCHOOL
FACILITY NUMBER: 330900976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/06/2022
Section Cited
CCR
101223(a)(3)

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Personal Rights -To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidenced by: Based on the LPA's interviews conducted and per staff's own admission the day in question.

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Licensee agrees to provide staff with training memo on Personal Rights to submit written statement of understanding from staff with their signatures by 01/07/2022. Licensee also agrees to provide in service training on how to protect the personal rights of the children while they are assigned to each staff; and Personal RIghts requirements to provide CCL with sign in sheet/ agenda of topic and date and time of training by 01/14/2022.
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Staff was aware of the child's obstructed nostril and failed to seek adequate medical attention in a timely manner. This is an immediate health and safety risk for the children in care.
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*********AMENDED REPORT************
CCR

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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:Aaron Ross
LICENSING EVALUATOR NAME:Karrene Turner
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2022


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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: TOWN AND COUNTRY DAY SCHOOL
FACILITY NUMBER: 330900976
VISIT DATE: 01/06/2022
NARRATIVE
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Continued, Page 2

101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).

101223(a)(3) Personal Rights. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

101212(d)(1)(C) Reporting Requirements. Any unusual incident or child absence that threatens the physical or emotional health or safety of a child shall be reported to the Department within 24 hours of the occurrence.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility for the next 12 months.

The Notice of Site Visit and Type A Deficiencies from today’s visit must be posted for 30 days. Failure to keep these posted for the entire 30 days will result in an immediate $100 civil penalty for each.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Karrene Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/06/2022 04:49 PM - It Cannot Be Edited


Created By: Karrene Phillips On 01/06/2022 at 10:46 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: TOWN AND COUNTRY DAY SCHOOL
FACILITY NUMBER: 330900976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2022
Section Cited
CCR
101212(d)(1)

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101212(d)(1)(C) Reporting Requirements. Any unusual incident or child absence that threatens the physical or emotional health or safety of a child shall be reported to the Department within 24 hours of the occurrence. The center failed to report the incident of Child#1 to community care licensing (CCL).
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Licensee agrees to provide staff with training memo on Reporting Requirements to submit written statement of understanding from staff with their signatures by 01/07/2022. Licensee also agrees to provide in service training on how to fill out LIC 624 Unusual Incident/Injury report in the absence of designated staff and to provide CCL with sign in sheet/ agenda of topic and date and time of training by 01/14/2022.
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This requirement was not met as evidenced by:
Based on LPA's interviews conducted and per staff’s own admission the day in question. Facility failed to report the incident for Child#1 to the Department and failed to ensure child’s follow up in timely manner for the obstructed nostril and the need that medical attention was sought. This presents a potential risk to health and safety risk for the children.

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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:Aaron Ross
LICENSING EVALUATOR NAME:Karrene Phillips
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2022


LIC809 (FAS) - (06/04)
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