376105113-9-28-2022-51-CC-GCUS-CJPUU8-20220928155308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376105113
Report Date: 09/28/2022
Date Signed: 09/28/2022 03:53:15 PM

Document Has Been Signed on 09/28/2022 03:53 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:	CLAIREMONT CANYONS ACADEMY STATE PRESCHOOL		FACILITY NUMBER:	376105113
ADMINISTRATOR:	VICTORIA PETERSON		FACILITY TYPE:	850
ADDRESS:	4133 MT ALBERTINE AVENUE		TELEPHONE:	(619) 605-1350
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92111
CAPACITY: 24	TOTAL ENROLLED CHILDREN: 24	CENSUS: 21	DATE:	09/28/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Victoria Peterson		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On September 28, 2022 at 1:35 p.m. Licensing Program Analyst, Leilani Curtis, conducted an unannounced inspection to follow up on a self-reported incident that occurred on 9/21/22, wherein a child (C1) sustained abrasions to his ribs due to a tricycle collision with two other children (C2 and C3). LPA met with Director/Principal Victoria Peterson and proceeded to tour the facility. There were 21 children with 3 staff members present. Appropriate ratio/capacity were observed. Staff members have the required background clearances. LPA interviewed the director, staff #1 (S1) and staff #2 (S2). On 9/21/22 at approximately 9:25 a.m. while riding tricycles C1 accidentally collided with C2 and C3. C1 and his tricycle tipped over and C1 sustained abrasions on his ribs. The child was treated by the nurse, ice and bandages were applied. The other two children (C2 and C3) were not injured. Facility staff failed to verbally notify the parent of C1 or give the parent a written report of the incident at the time of pick up. The father of C1 was notified later that day, at approximately 10:45 a.m. via a telephone call. Facility staff did not provide the parent of C1 a written report of the incident until the next day, 9/22/22. S1 observed the incident and comforted the child. At the time of the incident there were 21 children on the playground being supervised by 4 staff members. Appropriate ratio/supervision was in place. The staff members responded to the injury appropriately. LPA inspected the playground and tricycles. LPA observed the area to be free from hazards and the tricycles appear to be in good repair. The director states that she met with some staff members regarding the procedures for informing families of injuries, outdoor safety and supervision. The facility director/principal notified Community Care Licensing (CCL) of the incident via telephone on 9/22/22 and a written report of the incident was received on 9/27/22. See LIC809D for cited deficiency. An exit interview was conducted with the director/principal and appeal rights (LIC 9058) were discussed. The director’s/principal's signature on this form acknowledges receipt of these rights. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed the director/principal post notice of site visit.

SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

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 09/28/2022 03:53 PM - It Cannot Be Edited

Created By: Grace Curtis On 09/28/2022 at 03:03 PM

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: CLAIREMONT CANYONS ACADEMY STATE PRESCHOOL	FACILITY NUMBER: 376105113
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/12/2022 Section Cited CCR 101226(a)(2)	1 2 3 4 5 6 7	101226(a)(2) Health-Related Services:(a) The licensee shall immediately notify the child's authorized representative if the child becomes ill...(2) In the case of less serious injuries including, but not limited to, minor cuts, scratches and bites from other children requiring assessment and/or administration of first aid by staff, the licensee shall document the injury in the child's record and notify the child's authorized representative of the nature of the injury when the child is picked up from the center. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The director states that she will conduct a staff meeting regarding supervision, reporting requirements and health-related services. The director will send LPA a copy of the meeting agenda and staff sign in sheet via email by 10/12/22.
	8 9 10 11 12 13 14	Based on interviews conducted by LPA, facility staff failed to notify the parent/guardian of C1 that the child had been injured at the time the child was picked up from the facility on 9/21/22. This poses a potential health and safety risk to the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Tashima Daniel

LICENSING EVALUATOR NAME:

Grace Curtis

LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC809 (FAS) - (06/04)

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