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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700009
Report Date: 01/11/2023
Date Signed: 01/11/2023 06:37:50 PM

Document Has Been Signed on 01/11/2023 06:37 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:TSUMIKIFACILITY NUMBER:
376700009
ADMINISTRATOR:MIHO TAKAHASHIFACILITY TYPE:
850
ADDRESS:4811 MOUNT ETNA DRIVETELEPHONE:
(858) 571-7000
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 27DATE:
01/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:MaasaTIME COMPLETED:
06:45 PM
NARRATIVE
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On 1/11/23 at 2:00 PM, Licensing Program Analyst (LPA) Adrian Mangina visited the facility to conduct an unannounced annual inspection. Upon arrival LPA met with Teacher/Assistant Director Maasa Ishikawa and proceeded to tour the facility. During today's inspection, there were 27 children with 4 staff in 1 classroom. Appropriate ratios and capacity were observed. Appropriate care & visual supervision were also observed during the inspection while children were napping.

Furniture and age appropriate equipment is in good condition. Rooms have adequate heating, lighting, ventilation. Floors appear to be clean and safe. Bottled drinking water is readily accessible. Bathrooms are maintained with operational toilets and faucets with appropriate temperature. Paper towels and toilet paper are available. Bathroom is lighted and has ventilation. Bathroom is shared between preschool and private school. There is no waiver in place. Facility is using only hall/potential classroom as preschool space. Facility has added a private school with 20 children enrolled which is currently using classrooms 1, 2 and 3 and the foyer. Classroom #4 is currently being used as an office. Facility did not inform Department of change in classrooms or addition of school children. LPA unable to determine if the current configuration for preschool meets indoor space requirements or fire clearance requirements. At 3:00 PM LPA observed that 2 of 27 parents did not sign children in.. Food service area consists of a kitchen which is clean and free of hazards. Menu is posted. Adequate food is available for meals. Cleaning supplies are kept separate from food and are inaccessible to children. Storage containers for solid waste must have tight-fitting covers. Storage areas for poisons are locked. Director stated there are no firearms or other weapons on the premises. All foods/beverages capable of rapid spoiling are stored in covered containers at 45 F or less. The facility appears to be free of insects and rodents. There is an operational carbon monoxide detector and smoke alarm at the facility. Facility does not have disaster drill log. Facility does not have a disaster and mass casualty plan of action.

(continued on LIC809-C page 2)
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 01/11/2023 06:37 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 01/11/2023 at 05:23 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: TSUMIKI
FACILITY NUMBER: 376700009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(a)
Disaster and Mass Casualty Plan
(a) Each licensee shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above as facility does not have written disaster plan of action which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2023
Plan of Correction
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Facility Representative states will provide LPA with written disaster and mass casualty plan of action no later than close of bisiness 2/8/23.
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as facility does not have disaster drill log available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2023
Plan of Correction
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Facility represenative states will conduct a disaster drill and provide LPA with proof no later than close of business 1/8/23.
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:Renesha Askew
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023


LIC809 (FAS) - (06/04)
Page: 8 of 8
Document Has Been Signed on 01/11/2023 06:37 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 01/11/2023 at 05:23 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: TSUMIKI
FACILITY NUMBER: 376700009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239(f)(1)
Fixtures, Furniture, Equipment and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as trash cans in kitchen and class do not have tight fitting covers which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2023
Plan of Correction
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Licensee states will ensure that all trashcans used in the building have tight fitting covers and provide proof to LPA no later than close of business 2/8/23.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as five of five staff do not have current mandated reporter training certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2023
Plan of Correction
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Facility Representative states will ensure that all staff complete mandated reporter training and provide proof to LPA no later than close of business 2/8/23.
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:Renesha Askew
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 01/11/2023 06:37 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 01/11/2023 at 05:23 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: TSUMIKI
FACILITY NUMBER: 376700009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as staff 2, staff 3, staff 4 and staff 5 do not have complete staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2023
Plan of Correction
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Facility represenative states will ensure that all staff have complete files and will provide proof to LPA no later than close of business 2/8/23
Type B
Section Cited
CCR
101212(c)
Reporting Requirements:The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to, room additions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above as facility did not inform Department of addition of private school and additional children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2023
Plan of Correction
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Facility Representative states will provide LPA with an updated LIC999 and LIC610 to reflect changes and will obtain current fire clearance and provide proof to LPA no later than close of business 2/8/23.
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:Renesha Askew
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 8
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: TSUMIKI
FACILITY NUMBER: 376700009
VISIT DATE: 01/11/2023
NARRATIVE
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(LIC809-C page 2)

Outdoor play area is a fenced playground, Play equipment has sufficient material for cushioning. There are no bodies of water or weapons at this facility. Climbing structures, swings and slides are securely fixed to the ground. Area has shade sails and a covered area which used for shade. Equipment is age appropriate. Area has drinking water (water bottles) readily accessible, and grounds are free of debris or potential hazards.

LPAs reviewed medication storage. There are no children using medications at this time. At 4:00 PM LPA observed that 5 of 5 staff do not have current Mandated reporter training and four of five staff (staff 2, staff 3, staff 4, staff 5) do not have complete staff files. One staff member has current CPR and First Aid certifications. Five of five staff do not have required immunization records in file. Each personnel record contains documentation of educational background and training. LPA unable to determine if international transcripts meet Licensing requirements. Children’s records contain admission agreements and medical assessment. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Facility does not care for infants. LPA provided the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

(continued on LIC809-C page 3)
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8
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: TSUMIKI
FACILITY NUMBER: 376700009
VISIT DATE: 01/11/2023
NARRATIVE
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(LIC809-C page 2)

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

See LIC809 -D for Type B deficiencies cited and LIC9102 for technical assistance given.

Exit interview conducted and report was reviewed with the facility representative, Maasa Ishikawa. A notice of site visit was given and must remain posted for 30 days.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC809 (FAS) - (06/04)
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