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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600627
Report Date: 09/16/2022
Date Signed: 09/16/2022 01:45:32 PM

Document Has Been Signed on 09/16/2022 01:45 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:JEFF & DENI JACOBS CHILD DEVELOPMENT CENTERFACILITY NUMBER:
376600627
ADMINISTRATOR:ANNE PATZOLDFACILITY TYPE:
850
ADDRESS:2360 EAST JEWETT STREETTELEPHONE:
(858) 278-2571
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY: 144TOTAL ENROLLED CHILDREN: 87CENSUS: 66DATE:
09/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Anne PatzoldTIME COMPLETED:
01:55 PM
NARRATIVE
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On 09/16/2022 at 12:05pm, Licensing Program Analyst (LPA) Selina Siao conducted an unannounced site inspection for the purpose of follow-up on an incident that occurred on 09/01/2022 around 8:18am. A two year old child was observed through the classroom window sitting down on the chair by her classroom. The incident was self reported to Community Care Licensing by the facility with a written incident report that was received within the seven days requirement on 09/08/2022.

Information was obtained from the Director Anne Patzold and based on information obtained it appears that during the incident the classroom had 8 children with 3 staff members. (Title 5 program) Information gathered also indicates that the two year old child was left alone at the playground while the rest of the 7 children and three staff members were in the classroom at 8:18am. The child was brought back into her classroom approximately six minutes later at 8:24am. Director stated that the three staff members that were in charge for the children were placed on administrative leave on 09/1/2022 and they were terminated on 09/06/2022 as a result of the incident.

The following ratios were observed today: there were 66 children napping on cots supervised by 15 staff members in six classrooms. All staff members have the required background clearances and are associated to the facility.

See Lic 809D for type B deficiency cited today:

An exit interview was conducted and appeal rights were provided to facility representative. A notice of site visit was provided and it shall remain posted at the facility for 30 days.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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 09/16/2022 01:45 PM - It Cannot Be Edited


Created By: Selina Siao On 09/16/2022 at 01:19 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: JEFF & DENI JACOBS CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 376600627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision
No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Director stated that she will have an all staff meeting with all the staff members on 09/21/2022 and she will go over the name to face head count procedure and do some role play with them. Director will
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This requirement is not met as evidence that on 09/01/2022, a two year old child was left behind at the enclosed playground around 8:18am while the rest of the children and three staff members returned back into their classroom. The child was brought back into her classroom approximately six mintues later at 8:24am. This poses a potential health and safety risk to clients in care.

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submit a copy of the agenda along with the staff members sign in sheet to Licensing no later than 09/23/2022.

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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:Monica Cuddy
LICENSING EVALUATOR NAME:Selina Siao
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
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