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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600638
Report Date: 01/10/2024
Date Signed: 01/10/2024 03:50:34 PM

Document Has Been Signed on 01/10/2024 03:50 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:CHILDTIME CHILDREN'S CENTER - CHULA VISTA INFANTFACILITY NUMBER:
376600638
ADMINISTRATOR:JESSICA DORNFACILITY TYPE:
830
ADDRESS:770 RANCHO DEL REY PARKWAYTELEPHONE:
(619) 397-0165
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: DATE:
01/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jessica DornTIME COMPLETED:
01:00 PM
NARRATIVE
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On January 10, 2024 at 11:45 AM Licensing Program Analyst (LPAs), Adrian Castellon conducted an unannounced Case Management Inspection. LPA met with Director Jessica Dorn and discussed the purpose of the inspection. LPA arrived to investigate a self reported incident. On 12/12/2023, the facility self reported the incident to the SDCCRO via the Duty Line. The facility reports that on 12/11/2023 at approximately 11:00 AM, a 1 year old child #1 was observed climbing on a table in the classroom and while getting off the table back into the chair leaned down/forward and hit left eye on the edge of table. Child was bleeding. First aid was applied by staff (cleaned and iced). Report states that incident was observed by three staff members present in the classroom. Parent was advised of incident via telephone call and child was picked up and taken to receive professional medical treatment.

On today's date, LPA conducted interviews with two staff members present in the class at the time of the incident. LPA previously viewed video footage of the incident. Staff member observed on video had back turned to the incident. Per interviews, staff members did not observe child hit eye on the edge of the table. A type B deficiency is cited on today's date. Please see LIC809D.

Report was reviewed with director. Appeal rights were discussed and given to director. Notice of Site Visit must be posted for 30 days.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Adrian Castellon
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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 01/10/2024 03:50 PM - It Cannot Be Edited


Created By: Adrian Castellon On 01/10/2024 at 02:01 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: CHILDTIME CHILDREN'S CENTER - CHULA VISTA INFANT
FACILITY NUMBER: 376600638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2024
Section Cited
CCR
101429(a)(1)

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Responsibility for Providing Care and Supervision for Infants: (a) In addition to Section 101229, the following shall apply:
(1) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times.
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Director will submit a written plan detailing how required supervision will be provided by facility staff. Infant Staff shall review CCR Section 101429(a)(1). Director will hold a staff meeting discussing supervision responsibilities and requirements. Director will submit meeting agenda by all staff.
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This requirement was not met as evidenced by staff not being able to state that they witnessed child fall while in care. This may pose a threat to the health and safety of children in care.
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In December of 2023, the same plan of correction was completed due to same citation issued in October 2023. Extra help has been added during busy times (napping, feeding). Director states that she will seek advice for Human Resources for further corrective action. Positioning will be addressed when providing 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:Cynthia Gray
LICENSING EVALUATOR NAME:Adrian Castellon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024


LIC809 (FAS) - (06/04)
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