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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372001274
Report Date: 01/20/2022
Date Signed: 01/20/2022 11:22:15 AM

Document Has Been Signed on 01/20/2022 11:22 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:LIFEBRIDGE PRESCHOOL & DAYCARE CENTERFACILITY NUMBER:
372001274
ADMINISTRATOR:JULIE HENDRICKSONFACILITY TYPE:
850
ADDRESS:17645 WEST BERNARDO DRIVETELEPHONE:
(858) 485-5933
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY: 142TOTAL ENROLLED CHILDREN: 169CENSUS: 111DATE:
01/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Julie HendricksonTIME COMPLETED:
11:30 AM
NARRATIVE
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On 1/20/22 @ 10:30AM, LPAs Nancy Diaz and Selina Siao conducted an unannounced case management inspection. A tour of the facility was conducted with staff Nastassia Provencio. Observed present today were 111 preschool and kindergarten children.

According to Julie Hendrickson, there were 2 staff and 1 child who tested positive for COVID-19.

Type B deficiency is cited. Type B deficiency if not corrected poses a potential risk to the health, safety or personal rights of children in care.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
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 01/20/2022 11:22 AM - It Cannot Be Edited


Created By: Nancy Diaz On 01/20/2022 at 09:59 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: LIFEBRIDGE PRESCHOOL & DAYCARE CENTER
FACILITY NUMBER: 372001274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2022
Section Cited
CCR
101212(d)

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REPORTING REQUIREMENTS. Upon the occurrence... a report shall be made to the Department by telephone or fax within the Department's next working day... In addition, a written report containing the ...shall be submitted to the Department within seven days following the occurrence of such event. This requirement was not met as evidenced by:
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Mrs. Hendrickson stated that she will submit an unusual incident to report the COVID19 positives to the Department no later than 1/24/22. She will also train her staff regarding reporting requirements.
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Based on staff interviews, it was determined that facility failed to report cases of COVID-19 to the Department.
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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:Tashima Daniel
LICENSING EVALUATOR NAME:Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2022


LIC809 (FAS) - (06/04)
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