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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370806001
Report Date: 02/06/2023
Date Signed: 02/06/2023 04:52:12 PM

Document Has Been Signed on 02/06/2023 04:52 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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KIDS CORNER INC.FACILITY NUMBER:
370806001
ADMINISTRATOR:MICHAEL GOLOVKOFACILITY TYPE:
840
ADDRESS:1425 WASHINGTON PLACETELEPHONE:
(619) 295-8344
CITY:SAN DIEGOSTATE: CAZIP CODE:
92103
CAPACITY: 70TOTAL ENROLLED CHILDREN: 79CENSUS: 54DATE:
02/06/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Zackary GolovkoTIME COMPLETED:
05:00 PM
NARRATIVE
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On 2/6/23, at 3:45 pm, Licensing Program Analyst (LPA), Vicky Williamson arrived at the facility to conduct a case management inspection for the purpose of an annual continuation inspection. LPA met with Program Director, Zackary Golovko. There were 49 children, and four (4) staff member presents during today’s inspection.

The purpose of today's annual continuation inspection is to review and discuss the staff files that were reviewed during the annual required inspection on 2/1/23. The staff files reviewed were for all staff members that were present during the annual required inspection that was conducted on 2/1/23. LPA reviewed a sample of staff files and observed files were incomplete for Staff 1 (S1) and Staff 2 (S2). There was no health screening report or immunization records available for review for S1, and no immunization record for pertussis for S2 during the time of inspection. Staff files reviewed had documentation of completed mandated reporter training. On 2/1/23, LPA and Program Director discussed the incomplete staff files however due to a computer malfunction the facility report was unable to be completed.

LPA and Program Director Zackary Golovko discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, Mandated Reporter Training, California Megan’s Law (www.meganslaw.ca.gov).


Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiencies are being cited: See LIC 809D.

Exit interview conducted with Program Director and a copy of this report, Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit is required to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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Document Has Been Signed on 02/06/2023 04:52 PM - It Cannot Be Edited


Created By: Vicky Williamson On 02/06/2023 at 04:04 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KIDS CORNER INC.
FACILITY NUMBER: 370806001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2023

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 interview and record review, the licensee did not comply with the section cited above in 2 out of 4 staff members, as Staff 1 did not have immunization records available for review and Staff 2 did not have immunization for pertussis on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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4
Program Director stated that he will submit a copy of immunization records for Staff 1 and Staff 2 (pertussis only), to LPA Williamson, no later than 2/24/23.
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 4 staff members, as Staff 1 did not have a health screening report available for review during time of inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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Program Director stated that he will submit a copy of health screening report for Staff 1 to LPA Williamson, no later than 2/24/23.
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 Vu
LICENSING EVALUATOR NAME:Vicky Williamson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023


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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KIDS CORNER INC.
FACILITY NUMBER: 370806001
VISIT DATE: 02/06/2023
NARRATIVE
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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.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC809 (FAS) - (06/04)
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