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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600031
Report Date: 11/06/2024
Date Signed: 11/06/2024 03:02:15 PM

Document Has Been Signed on 11/06/2024 03:02 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CARMEL VALLEY PRESCHOOLFACILITY NUMBER:
376600031
ADMINISTRATOR/
DIRECTOR:		HOLLY SMITHFACILITY TYPE:
850
ADDRESS:13340 HAYFORD WAYTELEPHONE:
(858) 481-7933
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY: 125TOTAL ENROLLED CHILDREN: 125CENSUS: 93DATE:
11/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Holly SmithTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 11/6/24 at 2:20 PM, Licensing Program Analysts (LPAs) Keturah Lane and Mahjoba Mohsini conducted a case management visit at the facility. LPAs had arrived earlier at the facility at 10:20 AM for an unrelated visit and observed census to be 93 children in 11 classrooms with 11 staff members present.

During this case management visit, LPAs became aware that an unexplained injury was reported by a parent to a teacher around October 11th, 2024 and was not reported to the licensing department. As per regulatory requirements, facilities are required to submit an unusual incident report when there is an incident involving a child that results in an injury requiring medical treatment or raises health and safety concerns.

See LIC809D for Type B deficiency cited.

Exit interview conducted and report was reviewed with facility representative Director Holly Smith. Notice of site visit was provided and must be posted for 30 days.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 11/06/2024 03:02 PM - It Cannot Be Edited


Created By: Keturah Lane On 11/06/2024 at 02:31 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: CARMEL VALLEY PRESCHOOL
FACILITY NUMBER: 376600031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
101212(d)(1)(C)

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101212 Reporting Requirements (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported shall include the following(C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement was not met as evidenced by...
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Director stated she would report the unexplained injury that occurred to child C1 by 11/8/24 and e-mail the LIC624 Unusual incident report to: SDIncidentreports@dss.ca.gov
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Based upon Director interview, an incident report was not provided to Licensing regarding an unexplained injury that occurred to a child in care. The facility became aware of the unexplained injury when a parent reported it to a staff member, but did not report it to the licensing department which is 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:Tashima Daniel
LICENSING EVALUATOR NAME:Keturah Lane
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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