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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600689
Report Date: 12/09/2021
Date Signed: 12/09/2021 11:22:16 AM

Document Has Been Signed on 12/09/2021 11:22 AM - 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:CAJON VALLEY STATE PRESCHOOL - ANZA ELEMENTARYFACILITY NUMBER:
376600689
ADMINISTRATOR:CINDY KNIGHTFACILITY TYPE:
850
ADDRESS:1005 SOUTH ANZA STREETTELEPHONE:
(619) 588-3116
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 23TOTAL ENROLLED CHILDREN: 22CENSUS: 20DATE:
12/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Elsa Marta, PM Lead TeacherTIME COMPLETED:
11:35 AM
NARRATIVE
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On December 9, 2021 at 9:05 a.m. Licensing Program Analyst, Leilani Curtis conducted an unannounced inspection to follow up on a self-reported incident that occurred on 11/17/21. Upon arrival LPA toured the facility. There were 20 children present with 4 staff members. Appropriate ratios were observed. LPA met with the PM Lead Teacher, Elsa Marta

On Wednesday, 11/17/21 between 10:40 a.m. and 10:50 a.m. a daycare child (C1) walked out of the preschool classroom unsupervised. At the time of the incident there were three staff members and 18 children present in the classroom. The staff to child ratio was appropriate at the time. A parent (P1) opened the classroom door and notified a staff member (S1) that a child was outside. C1 was standing outside in the preschool area with parents who were waiting to pick up their children. The gate to the preschool area was open. Once S1 was notified that the child was outside, C1 was brought back into the classroom. The parent of the child (P2) spoke with S1 about the incident. The director and the AM Lead Teacher were notified of the incident.

During today’s inspection interviews were conducted with several staff members and C1. Information gathered indicates that C1 was left alone outside of the closed classroom door for an unknown amount of time before staff were notified by P1 that the child was not in the room. The child returned to care after the incident and was released to his/her parent, P2. Ms. Marta states that immediately after the incident visual supervision was discussed with the staff. They also discussed classroom expectations and safety procedures with the staff and children.

LPA observed that a rolling cubby shelf was placed at the door entrance to avoid children walking out of the classroom. LPA advised the AM Lead Teacher (Stacy Miller) and the PM Lead Teacher (Elsa Marta) that the classroom exit/door cannot be blocked as a way to keep children from exiting the classroom, adequate supervision must be provided.

See LIC 809D for deficiency cited today. A civil penalty has been assessed.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CAJON VALLEY STATE PRESCHOOL - ANZA ELEMENTARY
FACILITY NUMBER: 376600689
VISIT DATE: 12/09/2021
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An exit interview was conducted with Ms. Marta and Appeal Rights (LIC 9058 1/16) were discussed. Ms. Marta's signature on this form acknowledges receipt of these rights. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed Ms. Marta post notice of site visit.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of the Fact Sheet - AB 633 Child Care Parent Notification Requirements and a copy of LIC 9224 was given to licensee.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2021 11:22 AM - It Cannot Be Edited


Created By: Grace Curtis On 12/09/2021 at 10:43 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: CAJON VALLEY STATE PRESCHOOL - ANZA ELEMENTARY
FACILITY NUMBER: 376600689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2021
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time. This requirement was not met as evidenced by:
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Ms. Marta (PM Lead Teacher) states that she will conduct a staff meeting to discuss supervision. The AM Lead Teacher, Ms. Miller, will also conduct a staff meeting to discuss supervision. Ms. Marta will submit a copy of the meeting agenda and staff sign in sheets for both class sessions to LPA via email by POC due date of 12/17/21.
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Based on interviews conducted by LPA, a child (C1) was left unattended outside of the classroom in the preschool area on 11/17/21 for an unknown amount of time. This poses an immediate 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:Grace Curtis
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
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