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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376105113
Report Date: 10/03/2022
Date Signed: 10/04/2022 07:31:37 AM

Document Has Been Signed on 10/04/2022 07:31 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:CLAIREMONT CANYONS ACADEMY STATE PRESCHOOLFACILITY NUMBER:
376105113
ADMINISTRATOR:VICTORIA PETERSONFACILITY TYPE:
850
ADDRESS:4133 MT ALBERTINE AVENUETELEPHONE:
(619) 605-1350
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY: 24TOTAL ENROLLED CHILDREN: 0CENSUS: 21DATE:
10/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Victoria PetersonTIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/3/22 at 3:30 PM Licensing Program Analyst (LPA) Adrian Mangina conducted a case management -deficiencies. LPA met with Site Supervisor Victoria Peterson. During the visit, LPA reviewed staff files and found that 4 of 5 staff have incomplete files.

See LIC809 - D for deficiency cited.

Exit interview conducted. LPA reviewed and provided a copy of this report to Facility Representative Victoria Peterson. Notice of Site visit given, which must be posted for 30 days.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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 10/04/2022 07:31 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 10/03/2022 at 03:32 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: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2022
Section Cited
CCR
101217(a)

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PERSONNEL RECORDS: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee...

This requirement was not met as evidenced by:
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Facility representative staes will provide complete staff files for all staff listed no later than 10/31/22 and will in future ensure that all staff have complete files.
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Based on reorcd review staff 1, staff 2, staff 4 and staff 5 did not have complete staff files which poses a potential health, safety and personal rights risk to children 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.
SUPERVISOR'S NAME:Renesha Askew
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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