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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700075
Report Date: 11/21/2022
Date Signed: 11/21/2022 11:41:57 AM

Document Has Been Signed on 11/21/2022 11:41 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:LIBBY LAKE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
376700075
ADMINISTRATOR:CARMEN S. MACIASFACILITY TYPE:
850
ADDRESS:489 CALLE MONTECITOTELEPHONE:
(760) 754-1270
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 0DATE:
11/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Aljeandra Martir-Teacher and Jackeline Salgado-Teacher AssistantTIME COMPLETED:
11:45 AM
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On the date and time listed, Licensing Program Analyst (LPA) Andrea Taylor arrived at the facility to conduct a Case Management- Incident follow-up visit on an Unusual Incident Report (UIR) received by the Department on 10/13/2022. LPA met with Aljeandra Martir-Teacher and Jackeline Salgado- Teacher assistant to discuss the incident. A tour of the facility was granted, and census was conducted school for thanksgiving week staff working in classroom.

The incident involved a child trying to run up the stairs on the climbing/slide structure. Child's foot missed a step causing the child to fall forward and hit their head. Child did not make it up the first step before they fell.
Two staff members witness child trying to run up the stairs.

LPA examined the steps on the structure which are the usual steps and not slippery.

Based on the information gathered, there appears to be no violations of Title 22 Regulations found at this time. An exit interview was conducted, and a copy of this report was provided to teacher.

There were no deficiencies cited during this inspection. A Notice of Site Visit was issued and the Licensee understands that it must remain posted for 30 days.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Andrea Taylor
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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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