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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700787
Report Date: 06/07/2024
Date Signed: 06/07/2024 02:10:50 PM

Document Has Been Signed on 06/07/2024 02:10 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:ECS 4TH AND D HEAD STARTFACILITY NUMBER:
376700787
ADMINISTRATOR/
DIRECTOR:		JAQUELINE ANDRADEFACILITY TYPE:
850
ADDRESS:385 D STREETTELEPHONE:
(619) 591-9136
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 37TOTAL ENROLLED CHILDREN: 37CENSUS: 13DATE:
06/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Cecilia Evans-HernandezTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 6/7/2024, at 10:00 a.m., Licensing Program Analyst (LPA) Adrian Castellon conducted an unannounced Case Management inspection to follow upon on the Unusual Incident reported to the Department on 6/3/2024. Upon arrival, LPA met with Area Supervisor Cecilia Evans-Hernandez and discussed the purpose of the inspection. LPA was led on a tour of the facility. There were 13 children present and 8 staff during the inspection.

Based on interviews conducted and review of medical reports and facility notes, it was determined that on 5/22/24 and 6/3/24 Child #1 suffered a seizure during nap time in classroom 1A. Seizure was observed by facility staff (S1, S2, and S3). LPA requested video footage of the incidents.

Child's mother was immediately telephoned and advised of both incidents. Child was taken to Rady's Children's Hospital after both incidents and was cleared to return to the facility. LPA obtained copies of the medical reports.

Facility reported the incident of 6/3/24 to the licensing office in a timely manner but not the initial incident of 5/22/24. Parent requested that 911 not be called during first incident, but facility did call 911 during second incident.

Per California Code of Regulations, (Title 22, division 12 & Chapter 1) one (1) Type B citation is being cited on the attached LIC 809-D.




Exit interview conducted and report was reviewed with the facility representative, Cecilia Evans-Hernandez. Appeal Rights, and Notice of Site Visit were given. Notice of Site Visit is required to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. LPA observed Notice of Site Visit posted.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Adrian Castellon
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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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Document Has Been Signed on 06/07/2024 02:10 PM - It Cannot Be Edited


Created By: Adrian Castellon On 06/07/2024 at 12:43 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: ECS 4TH AND D HEAD START
FACILITY NUMBER: 376700787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2024
Section Cited
CCR
101212(d)(1)(C)

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101212 Reporting Requirements (d) Upon the occurrence "... a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours." In addition, a written report "... shall be submitted to the Department within seven days following
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Area Supervisor will submit LIC624b to the Licesning Office regarding inital incident of 5/22/24 by POC date. Area Supervisor will hold meeting with facility managment to discuss required reporting requirements. Area Supervisor will submit meeting minutes.
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the occurrence of such event." This requirement was not met as evidenced by facility not reporting to the Licensing Office that C1 suffered a seizure whie in care. This may pose a threat to the health and safety of 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:Cynthia Gray
LICENSING EVALUATOR NAME:Adrian Castellon
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
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