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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372005909
Report Date: 05/04/2023
Date Signed: 05/04/2023 10:29:35 AM


Document Has Been Signed on 05/04/2023 10:29 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:TEMPLE ADAT SHALOM-GANON GIL PRESCHOOLFACILITY NUMBER:
372005909
ADMINISTRATOR:MARILYN MILNEFACILITY TYPE:
850
ADDRESS:15905 POMERADO ROADTELEPHONE:
(858) 451-1200
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:45CENSUS: 28DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Marilyn MilneTIME COMPLETED:
10:45 AM
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On 5/4/2023 @8:45am, Licensing Program Analyst (LPA) Patrick Ma, visited the facility to conduct a Case Management site visit. The purpose of this visit is to follow up on a self reported incident that occurred on 4/20/2023 where Child #1 (C1) sustained an injury on the playground. Upon arrival, LPA met with Director, Marilyn Milne. Present at the facility were 28 daycare children and 8 staff in 3 rooms.

LPA conducted interview of staff (S1 – S3), made a confidential names list, reviewed related documents, and received a copy of the children’s roster. Teachers and children were observed in ratio with staff providing proper supervision of the children.

No deficiencies were cited during this visit.

Exit interview conducted and report was reviewed with the facility representative Marilyn Milne. A notice of site visit was given and must remain posted for 30 days
SUPERVISOR'S NAME: Renesha AskewTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Patrick MaTELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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