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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603968
Report Date: 06/18/2025
Date Signed: 06/18/2025 11:23:25 AM

Document Has Been Signed on 06/18/2025 11:23 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:A.B. JESSIE POLINSKY CHILDREN'S CENTERFACILITY NUMBER:
374603968
ADMINISTRATOR/
DIRECTOR:		ROSAS, ELIZABETHFACILITY TYPE:
721
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 204TOTAL ENROLLED CHILDREN: 0CENSUS: 18DATE:
06/18/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Steven Wells, Acting Deputy DirectorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On June 18, 2025, at 10:20 AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced inspection at the facility and met with Steven Wells, Acting Deputy Director for the purpose of following up on the case management inspection conducted on 2/25/2025 regarding a Serious Incident Report (SIR) dated 2/18/2025. LPA conducted interviews with Clients (C3 and C4), Staff (S1-S6), and a county social worker. LPA attempted to interview C1 and C2 but was unable despite multiple attempts and due to C1 declining. LPA obtained and reviewed pertinent records.

Community Care Licensing (CCL) was made aware of an incident that occurred on 2/18/2025 wherein S1 was observed grabbing C1's sweater, pushing C1 towards a wall, opening one of the bedroom doors, forcefully pushing C1 inside, and closing the door behind him, due to an unprovoked physical assault of S1. A confidential interview indicated that S1 did not restrain C1 in an aggressive manner but instead defensively held C1’s arms, and that S1 was pushed by another client, C3, into C1 as S1 and C1 went falling into another room. A conflicting confidential interview indicated that in reaction to C1’s assaultive behavior, S1 restrained C1 by their clothing and placed C1 in another room. Another conflicting interview indicated that S1 forcefully grabbed C1 by the sweater, pushed C1 into a wall, and threw C1 into another room. Further confidential interviews indicated that S1 grabbed and threw C1 to the ground. Although the details of the incident vary, confidential interviews indicated that S1 did not call for a restraint or request support from other staff present while taking hold of C1’s clothing and moving C1 to another room. Confidential interviews indicated that C1 was not injured from the incident; however, C1 declined to see nursing. A records review indicated that S1 had recently been trained in appropriate physical restraint and emergency intervention.

CONTINUED...

Dawn SeguraTELEPHONE: (951) -782-4207
Jacob SalemTELEPHONE: (619) 767-2301
DATE: 05/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: A.B. JESSIE POLINSKY CHILDREN'S CENTER
FACILITY NUMBER: 374603968
VISIT DATE: 06/18/2025
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...CONTINUED

Confidential interviews and records reviewed indicated that the licensee immediately reported the incident per State regulations and assigned S1 to work away from the facility upon discovery of the incident pending the investigative findings.

Based on confidential interviews, the facility is being cited for a Type A violation of the California Code of Regulations, Title 22, Division Six, Chapter 5, subchapter 3, regulation 84300.1(b) Emergency Intervention Prohibition.

An exit interview was conducted and a copy of this report along with appeal rights and LIC 811 Confidential Names List were provided to Steven Wells, Acting Deputy Director.

SUPERVISOR'S NAME: Dawn SeguraTELEPHONE: (951) -782-4207
LICENSING EVALUATOR NAME: Jacob SalemTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2025 11:23 AM - It Cannot Be Edited


Created By: Jacob Salem On 06/18/2025 at 08:28 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. #109
SAN DIEGO, CA 92108

FACILITY NAME: A.B. JESSIE POLINSKY CHILDREN'S CENTER
FACILITY NUMBER: 374603968

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2025
Section Cited

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84300.1(b) Emergency Intervention Prohibition “…any emergency intervention technique not approved for use as part of the licensee's emergency intervention plan must not be used at any time.” This requirement was not met as evidenced by:
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Based on confidential interviews and records reviewed, the licensee did not ensure that approved emergency intervention technique was used on 1 of 31 clients in care (C1), which poses an immediate health, safety, or personal rights risk to persons 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.
Dawn Segura
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (951) -782-4207
Jacob Salem
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (619) 767-2301
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
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