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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700009
Report Date: 01/18/2023
Date Signed: 01/18/2023 10:59:25 AM

Document Has Been Signed on 01/18/2023 10:59 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: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:
01/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Maasa IshikawaTIME COMPLETED:
11:15 AM
NARRATIVE
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On 1/18/23 at 8:00 AM Licensing Program Analysts (LPA’s), Adrian Mangina and Nancy Diaz conducted an unannounced Case Management inspection for the purpose of measuring the preschool classroom and outdoor play area due to changes in the configuration of the preschool. LPAs also cleared POCs from the last facility visit. LPAs met with Lead Teacher Maasa Ishikawa and toured the facility. At 8:00 AM there were 8 children present with one qualified teacher (Director Miho Takahashi) and three staff whose qualifications are unknown pending translation and review of transcripts. As of 10:10 AM there were a total of 27 children.

During the visit, LPAs measured Preschool classroom. At 8:30 AM LPA's observed that parents continue to use only initials on sign in sheets. Facility representative was reminded that the Technical Violation given 1/11/23 stated that sign in sheets must have full signatures. While measuring the Preschool Classroom, at 8:45 AM LPAs observed that the nap mats are worn and ripped and need replacement. At 8:50 AM LPAs observed that the carpet in the preschool room is ripped along the length in several places. At 8:55 AM LPAs observed that the following hazardous areas are accessible to children: closet in preschool room, faculty room off entrance hallway to preschool room, kitchen, utility closet and office off hallway to private school classrooms.. At 9:05 AM, while measuring the outdoor space LPAs observed that there were multiple cracks and bumps in the concrete throughout the outdoor space which pose tripping hazards.

See LIC809 -D for deficiencies cited.

Exit interview conducted and copy of this report was provided to Facility Representative, Maasa Ishikawa. . A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2023
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 3
Document Has Been Signed on 01/18/2023 10:59 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 01/18/2023 at 09:32 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: TSUMIKI
FACILITY NUMBER: 376700009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2023
Section Cited
CCR
101229.1(a)(1)

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SIGN IN AND SIGN OUT: The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement was not met as evidenced by:
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Liceensee states will ensure that parents use full name when signing in and out and will provide 25 days of sign in sheets as proof to LPA no later than close of business 2/15/23.
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Based on observation, the licensee did not comply with the section cited above as sign in sheets are signed with initals only and do not have full names of the individuals picking up children which poses a potential health, safety or personal rights risk to persons in care.
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Type B
02/15/2023
Section Cited
CCR101238(a)

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BUILDINGS AND GROUNDS: The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
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Licensee states will repair concrete cracks and bumps on playground and will repair/replace ripped carpet in preschool room and provide proof to LPA no later than close of business 2/15/23.
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Based on observation, the licensee did not comply with the section cited above as there is ripped carpet in prescool room and cracked and bumpy concrete throughout the outdoor play space which poses a potential health, safety or personal rights risk to persons 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:Renesha Askew
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/18/2023 10:59 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 01/18/2023 at 09:46 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: TSUMIKI
FACILITY NUMBER: 376700009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2023
Section Cited
CCR
101239.1(B)(5)

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NAPPING EQUIPMENT: Floor mats used for napping shall be...Maintained in a safe condition with no exposed foam.
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Licensee states will replace all ripped mats to ensure that every child has an intact mat and will provide proof to LPA no later that close of business 2/15/23.
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Based on observation, the licensee did not comply with the section cited above as napping mast are ripped with exposed foam which poses a potential health, safety or personal rights risk to persons in care.
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Type B
02/15/2023
Section Cited
CCR101238(b)

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BUILDINGS AND GROUNDS: All children shall be protected against hazards within the center...
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Licensee states will make the following areas inaccessible to children: Faculty room, utility closet, preschool closet, kitchen, and office.
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Based on observation, licensee did not comply with the section cited above as these hazardous areas were not inaccessible to children: preschool closet, utility closet, kitchen office in hallway to private school & faculty room off preschool room hall which poses a potential health, safety or personal rights risk to persons 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:Renesha Askew
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023


LIC809 (FAS) - (06/04)
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