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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376105047
Report Date: 04/05/2023
Date Signed: 04/05/2023 03:52:10 PM

Document Has Been Signed on 04/05/2023 03:52 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:PRIMROSE SCHOOLS 4S RANCHFACILITY NUMBER:
376105047
ADMINISTRATOR:BREEANNA MOTAFACILITY TYPE:
830
ADDRESS:17025 VIA DEL CAMPOTELEPHONE:
(858) 592-2335
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 30DATE:
04/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Breeanna MotaTIME COMPLETED:
04:00 PM
NARRATIVE
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On 04/05/2023 at 1:45pm, Licensing Program Analyst, (LPA), Selina Siao conducted a case management inspection to follow with a self reported incident that occurred on 03/16/2023 in the infant room #10. Upon arrival, LPA Siao met with Director Breeanna Mota and licensee Reena Dayal who were in the office. LPA conducted a tour of the classrooms to gather census. LPA Siao observed 30 infants supervised by 7 staff members in three classrooms. Facility was within staffing ratio during the inspection. All staff members have the required background clearances.

On 03/16/2023, staff #1 mistakenly feed infant #1's bottle of breast milk that is labeled to infant #2 at 12:20pm. At 2:45pm it was discovered by staff #2 that child #1 was fed the wrong bottle by going over the infant's bottle counts. Upon review of the children's items, staff members identified that child #2 had four empty bottles but only had three tracked bottle feeding time. Facility informed both infants parents about the incident. As a result of the incident, facility implemented a new one touch bottle feeding form in the classroom with emergency verification on the form when there is a need to switch staff member during the feeding time. The staff members involved were counseled and all infant staff members has been retrained on bottle tracking and feeding procedures on 03/17/2023.

LPA Siao contacted child #1's parent and was informed that her child did not had any allergy reaction as a result of being fed with another child's bottle. LPA Siao inspected the feeding bottles and bottles are properly labeled with the child's name and the date. Interviews were also conducted with several staff members today.

See LIC809D for type B deficiency cited. Notice of site visit was posted and must remain posted for 30 days.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/05/2023 03:52 PM - It Cannot Be Edited


Created By: Selina Siao On 04/05/2023 at 10:12 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: PRIMROSE SCHOOLS 4S RANCH
FACILITY NUMBER: 376105047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
101216.1(a)

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Personnel Requirements-
Child care center personnel shall be competent to provide the services necessary to meet the individual needs of children in care and shall at all times be employed in numbers sufficient to meet those needs. This requirement is not met as evidence by:
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Director stated that all staff members involved were counseled and all infant staff members has been retrained on bottle tracking and feeding procedures on 03/17/2023.
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On 03/16/2023, staff #1 fed the wrong bottle of milk to infant #1 because she did not clearly verify the bottle information prior to feeding. Infant#1 did not sustain any allergic reaction to the wrong bottle of breast milk. This is a potential health and safety risk to children in care if not corrected.
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Director stated that she will submit the agenda along with the staff members's name and signed in sheet to LPA with the updated bottle verfication form by 04/14/2023.

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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:Monica Cuddy
LICENSING EVALUATOR NAME:Selina Siao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023


LIC809 (FAS) - (06/04)
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