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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600323
Report Date: 07/29/2021
Date Signed: 07/29/2021 01:26:11 PM

Document Has Been Signed on 07/29/2021 01:26 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:KINDERCARE GOLFCREST INFANTFACILITY NUMBER:
376600323
ADMINISTRATOR:MICHELLE MELTONFACILITY TYPE:
830
ADDRESS:7007 GOLFCREST DRIVETELEPHONE:
(619) 461-5771
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 32TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
07/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Michelle MeltonTIME COMPLETED:
01:30 PM
NARRATIVE
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On 7/29/21, Licensing Program Analyst (LPA), Tyra Block, conducted an unannounced Case Management Inspection to follow-up on a self-reported incident received 7/28/21 from Katrina Hoffman, Assistant Director. LPA interviewed Staff #1 who was directly involved in the incident, addition to District Leader Laura Burden.

Staff #1 acknowledged that a bottle of breast milk labeled for Child #2 was given to Child #1 by mistake. Staff #2 discovered the mistake upon return from break and the Assistant Director was immediately notified who then notified the District Leader. The parents of both children were notified and Staff #1 along with the other staff in the infant room were trained on proper procedures for handling bottles including "Name to Face" checks to avoid future mistakes with bottle feeding. Copy of training with staff signatures was provided to LPA.

A Type B deficiency is being cited today. Please see 809-D.

The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Tyra Block
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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 07/29/2021 01:26 PM - It Cannot Be Edited


Created By: Tyra Block On 07/29/2021 at 01:00 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: KINDERCARE GOLFCREST INFANT
FACILITY NUMBER: 376600323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2021
Section Cited
CCR
101223(a)(2)

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101223(a)(2) Personal Rights- To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.. This requirement was not met as evidenced by:
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Training was provided and documented on 7/28/21 (Requirements for Handling...Breast Milk...) Staff will check the name on the bottle when taking form the refrigerator, warming, and before giving the bottle to the child.
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Based on interviews and records reviewed staff fed a child a bottle that did not belong to the child. This provides a potential health and safety 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:Tyra Block
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021


LIC809 (FAS) - (06/04)
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