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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334841029
Report Date: 07/21/2021
Date Signed: 07/22/2021 11:04:06 AM

Document Has Been Signed on 07/22/2021 11:04 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:CATALYST KIDS - MENIFEEFACILITY NUMBER:
334841029
ADMINISTRATOR:RACHEL M SMITHFACILITY TYPE:
850
ADDRESS:25625 BRIGGS ROADTELEPHONE:
(951) 928-4000
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 144TOTAL ENROLLED CHILDREN: 0CENSUS: 31DATE:
07/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:39 PM
MET WITH:Center Manager- Rachel SmithTIME COMPLETED:
05:20 PM
NARRATIVE
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During the course of the investigation, LPA verified that an Unusual incident occurred on or around 3/30/21 was not Communicated with CCLD by phone within 24 hours of the incident occurring or LIC624 form filed within 7 days as required .

Center Manager did not call or notify licensing until a police report was filed, therefore (see LIC 809D for deficiency)

Exit interview conducted with Center Manager and Notice of Site visit given. LPA observed posting.

Appeal rights issued and discussed
SUPERVISORS NAME: Dawn Parker
LICENSING EVALUATOR NAME: Otsanya Cameron
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/22/2021 11:04 AM - It Cannot Be Edited


Created By: Otsanya Cameron On 07/21/2021 at 04:40 PM
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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CATALYST KIDS - MENIFEE
FACILITY NUMBER: 334841029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2021
Section Cited
CCR
101212(d)

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101212(d) Upon the occurrence, during the operation of the childcare center of any of the events specified in (d)(1) below, a report shall be made to the Dept. by telephone. In addition, a written report containing the information shall be submitted to the Dept within 7 days following the occurrence of such event.
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Center manager has conducted staff meeting on Injury reports and daily health checks on 5/20/21 and will conduct additional training on 8/5/21 to keep staff updated.
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Events reported shall include the following:(C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
This requirement was not met as evidenced by:
-----------------------------------------------------}
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-----Facility manager failed to report unusual incident that occured on 3/30/21. A report was sent to the dept following a visit from menifee PD. This poses a potential risk to children 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:Dawn Parker
LICENSING EVALUATOR NAME:Otsanya Cameron
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2021


LIC809 (FAS) - (06/04)
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