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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700685
Report Date: 08/27/2021
Date Signed: 08/27/2021 02:43:28 PM

Document Has Been Signed on 08/27/2021 02:43 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:SACRED HEART ACADEMY PRESCHOOLFACILITY NUMBER:
376700685
ADMINISTRATOR:WYDRA, SUZIEFACILITY TYPE:
850
ADDRESS:4895 SARATOGA AVENUETELEPHONE:
(619) 222-7252
CITY:SAN DIEGOSTATE: CAZIP CODE:
92107
CAPACITY: 137TOTAL ENROLLED CHILDREN: 0CENSUS: 36DATE:
08/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Suzie Wydra and Rebecca GodinaTIME COMPLETED:
03:00 PM
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On August 27, 2021 at 1:50pm, Licensing Program Analyst (LPA), Martha Malane conducted an unannounced case management inspection in response to an unusual incident report (UIR) regarding a 4-year-old child who tripped and incurred a fracture on their elbow. Upon arrival, LPA met with Director, Suzie Wydra and Assistant Director Rebecca Godina and disclosed the purpose of the inspection and was led on a tour. The facility self-reported the incident to the Department on 8/25/2021. The facility reported the following: The child was walking to line up and tripped. The child stated their arm hurt, ice was applied and the child was picked up from school on 8/25/2021 at 12:30pm. The child was taken directly to Kaiser Permanente where they were diagnosed with a slight fracture on the elbow. At the time of the incident, there were 10 children being supervised outside by the director.

Interviews were conducted with the director, assistant director, parents and children in care. According to the director, the child in question was walking and tripped and fell on the poured rubber cushioning in the covered playground area. The child stood up and started walking again then stated their arm hurt. LPA conducted an inspection of the outside area for health and safety and did not observe any tripping hazards or safety issues during the inspection. However, the director stated the facility is in the process of replacing the existing pour rubber with new poured rubber. Appropriate care and supervision including staffing ratios were observed during today’s inspection. Based on disclosure from interviews, it was determined this incident was accidental.

No deficiencies cited during today's inspection. A copy of this report and appeal rights (LIC 9058) was printed and given to the director. Director was advised to post the LIC 9213 for 30 days. An exit interview was conducted with the director.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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