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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376105070
Report Date: 09/03/2021
Date Signed: 09/03/2021 10:27:31 AM

Document Has Been Signed on 09/03/2021 10:27 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:CAJON VALLEY MADISON ELEMENTARY STATE PRESCHOOLFACILITY NUMBER:
376105070
ADMINISTRATOR:STEPHANIE DODDSFACILITY TYPE:
850
ADDRESS:1615 EAST MADISON AVENUETELEPHONE:
(619) 588-3077
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 48TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/03/2021
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Virgnia aka Ginny Pinkerton/Director of Early Childhood ProgramsTIME COMPLETED:
10:30 AM
NARRATIVE
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On 09/03/2021 at 9:40am, Licensing Program Analyst (LPA) Selina Siao conducted a scheduled visit to confirm that the program has ceased operation. LPA met with Director of Early Childhood Program Ginny Pinkerton and conducted a tour of the classroom. Three preschool staff members were observed.

The initial change of location application was received from the applicant on 07/07/2021. Department was informed by the pending facility representative on 08/24/2021, that the program had been operating prior to licensure. On 08/31/2021, facility representative was informed that the program had to cease operation until the license is approved.

On 09/01/2021, facility representative informed the department that they will cancel both preschool sessions on Friday to move back to the previously licensed classroom at Cajon Valley State Funded Preschool Program in room 204 to minimize disruption to the children in care. Room 204 was toured and has appropriate furniture and equipment.

During today's inspection, LPA Siao confirmed that the preschool program is not operating.

Notice of operation in violation of law was letter was provided to facility representative today. See LIC809D for citation issued.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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 09/03/2021 10:27 AM - It Cannot Be Edited


Created By: Selina Siao On 09/03/2021 at 08:55 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: CAJON VALLEY MADISON ELEMENTARY STATE PRESCHOOL
FACILITY NUMBER: 376105070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2021
Section Cited
HSC
1596.80

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1596.80-Child day care facilities, licenses. No person, firm, partnership, association, or corporation shall operate, establish, manage, conduct, or maintain a child day care facility in this state without a current valid license, therefore as provided in this act.
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Facility representative has moved the program to the previously licensed location located at Cajon Valley State Funded Preschool Program Room 204. Facility representative understands that the pending facility
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This requirement was not met as evidenced by: Facility was operating prior to approval of the license. This poses a potential health and safety risk to clients in care.

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cannot operate at this location until the license is approved by the Licensing Department.

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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: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021


LIC809 (FAS) - (06/04)
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