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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372005946
Report Date: 07/16/2025
Date Signed: 07/16/2025 12:11:04 PM

Document Has Been Signed on 07/16/2025 12:11 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:ST. COLUMBA PRESCHOOLFACILITY NUMBER:
372005946
ADMINISTRATOR/
DIRECTOR:		CLARISSA CARVERFACILITY TYPE:
850
ADDRESS:3365 GLENCOLUM DRIVETELEPHONE:
(858) 279-0161
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 60TOTAL ENROLLED CHILDREN: 47CENSUS: 40DATE:
07/16/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Clarissa CarverTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 07/16/2025 at 9:40 AM, Licensing Program Analyst (LPA) Adriana Macias, conducted an
unannounced case management inspection to follow up on a self-reported unusual incident. Incident took
place on 05/30/2025 and was self-reported. Upon arrival, LPA met with Director Clarissa Carver, discussed purpose of visit and toured the facility. There was a total census of 40 children today and 5 staff. Appropriate ratios were observed and all staff were fingerprinted and associated.

Incident reported involved a child (C1) who was climbing a tunnel looking structure during pick up time. C1 jumped off the climbing structure that is about 21 inches high and landed on hard turf, breaking her right tibia. Parent (P1) and staff member (S1) were present during the incident and attended to the child immediately. During today’s inspection, LPA did not observe appropriate cushioning around the tunnel play structure. Director stated that a big round padding was being used for the children to land on when jumping, but that the child did not land on the padding. Even though the tunnel play structure seems to be designed for climbing, children should not have been allowed to jump off without the appropriate cushioning underneath the whole area. Director stated that staff and children have been made aware that children are not allowed to climb on top of the tunnel play structure anymore.

Interviews conducted determined that C1’s injury could have been prevented if there was enough cushioning underneath the structure for the child to land on. Pursuant to Title 22 of the CA Code of Regulations, the following Type B deficiency was cited (refer to LIC 809-D). Exit interview was conducted and report was reviewed with Director Clarissa Carver.
LPA provided a copy of the report and appeal rights. A notice of site visit was provided and must remain
posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Joelle Redding
NAME OF LICENSING PROGRAM ANALYST: Adriana Macias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/16/2025 12:11 PM - It Cannot Be Edited


Created By: Adriana Macias On 07/16/2025 at 11:33 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: ST. COLUMBA PRESCHOOL
FACILITY NUMBER: 372005946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/23/2025
Section Cited
CCR
101238.2(e)

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101238.2 Outdoor Activity Space
(e) As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls.
This requiremenet was not met as evidenced by:
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Director stated that all children have been communicated of the new rule of not climbing or jumping on the tunnel play structure.
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Based on LPA's inspection, Director interview, and parent interview, it was determined that C1's injury could have been prevented, if there had been appropriate cushioning underneath tunnel play structure, or if children had not been allowed to climb or jump from playstructure on the first place.
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Director also stated that even though all staff have also been made aware of this new rule, they will all be asked to sign a date a written statement of their understanding to not allow children to climp/jump on top of the tunnel play structure.

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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.
Joelle Redding
NAME OF LICENSING PROGRAM MANAGER:
Adriana Macias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2025


LIC809 (FAS) - (06/04)
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