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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372000501
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:54:52 PM

Document Has Been Signed on 07/28/2023 02:54 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:SAN CARLOS UNITED METHODIST WEEKDAY PRESCHOOLFACILITY NUMBER:
372000501
ADMINISTRATOR:WENDY KOZAFACILITY TYPE:
850
ADDRESS:6554 COWLES MOUNTAIN BOULEVARDTELEPHONE:
(619) 464-4335
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 122TOTAL ENROLLED CHILDREN: 122CENSUS: 95DATE:
07/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Wendy KozaTIME COMPLETED:
02:10 PM
NARRATIVE
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On 7/28/2023 @11:10am, Licensing Program Analysts (LPAs) Patrick Ma and Martha Avila, made an unannounced Case Management inspection regarding a self-reported incident that occurred on 7/12/23. It was reported child was left unsupervised for a brief period. Upon arrival, LPA’s met with Director Wendy Koza and provided name, badges, and purpose of visit. Present at the facility were 95 daycare children with 16 staff in 9 rooms.

During this visit, LPAs interviewed staff and children, toured the facility, and reviewed related documents. Child was observed outside of the classroom unsupervised and quickly brought back in by a teacher.

See 809D for deficiency cited.

Exit interview conducted and report was reviewed with the facility representative Wendy Koza. A notice of site visit was given to Director and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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 07/28/2023 02:54 PM - It Cannot Be Edited


Created By: Patrick Ma On 07/28/2023 at 01:51 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: SAN CARLOS UNITED METHODIST WEEKDAY PRESCHOOL
FACILITY NUMBER: 372000501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
101229(a)(1)

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No child(ren) shall be left without the supervision of a teacher at any time...

This requirement is not met as evidenced by:
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Deficiency was clear on the day of deficiency.
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Based on records review and interviews with staff and children, child C1 was observed unsupervised breifly outside of her classroom but remained in the fully gated campus. This poses an potential health and safety 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:Renesha Askew
LICENSING EVALUATOR NAME:Patrick Ma
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
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