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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372005593
Report Date: 04/13/2022
Date Signed: 04/13/2022 01:13:37 PM

Document Has Been Signed on 04/13/2022 01:13 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:KLASSIC KIDS DAY CAMP - ERICSON ELEMENTARY SCHOOLFACILITY NUMBER:
372005593
ADMINISTRATOR:DAVID NGUYENFACILITY TYPE:
840
ADDRESS:11174 WESTONHILL DRIVETELEPHONE:
(858) 265-9761
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 62TOTAL ENROLLED CHILDREN: 40CENSUS: 33DATE:
04/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:David NguyenTIME COMPLETED:
01:20 PM
NARRATIVE
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On 4/13/2022 @ 12:25PM, LPA Nancy Diaz conducted an unannounced case management inspection. LPA met with David Nguyen (Site Supervisor). The purpose of this inspection is to follow-up on an unusual incident that happened on 3/16/2022 involving two boys who were caught in inappropriate activity inside the bathroom.

Observed present today were 33 school-age children with staff David Nguyen Kaylee Hobdy and Andrea Morales.

Included in today's discussion was the incident on 3/16/2022. According to Mr. Nguyen during transition time, 2 children went into the bathroom without staff knowledge and engaged in inappropriate activity. Mr. Nguyen stated that the facility's rule (regarding bathroom use) has changed since the incident. Only one child is allowed to use the bathroom and a staff is required to stand outside by the door.

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.

An exit interview was conducted with Mr. Nguyen. A copy of this report and appeal rights were provided to Mr. Nguyen.

Notice of site visit was observed posted today. Mr. Nguyen provided the following updated forms today: Children's Roster; LIC 500 & LIC 610.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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 04/13/2022 01:13 PM - It Cannot Be Edited


Created By: Nancy Diaz On 04/13/2022 at 12:57 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: KLASSIC KIDS DAY CAMP - ERICSON ELEMENTARY SCHOOL
FACILITY NUMBER: 372005593

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2022
Section Cited
CCR
101129(a)(1)

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Responsibility for Providing Care and Supervision. No child(ren) shall be left without the supervision of a teacher at any time...

This regulation requirement was not met as evidenced by:
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Mr. Nguyen stated that he notified both parents of the children involved. As part of his correction, he will meet with his staff and discuss "Supervision of Children at all times" and also remind staff about the new rule about ensuring that staff supervise one child at a time in the bathroom.
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Based on Mr. Nguyen statement regarding the incident of 3/16/2022, it was determined that staff failed to provide sufficient visual supervision to two children who admitted to the school principal that they were engaged in an inappropriate activity in the bathroom.
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Mr. Nguyen shall submit documentation of the training - to include the topics covered and signature of staff who attended the training. This document is due to the department no later than 4/20/2022 via email to nancy.diaz@dss.ca.gov

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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: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
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