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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376105113
Report Date: 11/07/2022
Date Signed: 11/30/2022 01:57:38 PM

Document Has Been Signed on 11/30/2022 01:57 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 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: 24CENSUS: 0DATE:
11/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Victoria PetersonTIME COMPLETED:
03:45 PM
NARRATIVE
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THIS IS AN AMENDED COPY OF A VISIT REPORT DELIVERED ON 11/30/22.

On 11/7/22 at 2:45 PM Licensing Program Analyst (LPA) Adrian Mangina conducted a case management -deficiencies for the purpose of providing the LIC 809D for the citation that was missing from the report provided on 11/4/22 due to a system error. LPA met with Site Supervisor Victoria Peterson. During the visit on 11/4/22, LPA reviewed staff files and found that 3 of 5 staff continue tohave incomplete files. There were no children in care today as the school day was over.

See LIC809 - D for deficiency cited.

Exit interview conducted. LPA reviewed and provided a copy of this report to Facility Representative Victoria Peterson as well as an additional copy of the 11/4/22 visit report. Notice of Site visit given and must remain posted for 30 days.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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 11/07/2022 03:25 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 11/07/2022 at 07:01 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: CLAIREMONT CANYONS ACADEMY STATE PRESCHOOL
FACILITY NUMBER: 376105113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2022
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 provided documents for staff #2 but does not have documents for staff #3 yet. She also states that staff #1 is out until 11/18/22 and cannot provide documents until staff returns. Facility Representative states will provide reamaining missing documents to LPA no later than close of business 12/5/22.
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Based on reoord review staff 1, staff 2 and staff 3 still do 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: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022


LIC809 (FAS) - (06/04)
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