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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700945
Report Date: 11/18/2022
Date Signed: 11/18/2022 12:01:01 PM

Document Has Been Signed on 11/18/2022 12:01 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:CAPSLO MIDLAND HEAD STARTFACILITY NUMBER:
376700945
ADMINISTRATOR:JAYALAKSHMI IYERFACILITY TYPE:
850
ADDRESS:13910 MIDLAND ROADTELEPHONE:
(858) 391-0216
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 40TOTAL ENROLLED CHILDREN: 29CENSUS: 10DATE:
11/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Suong LeTIME COMPLETED:
12:30 PM
NARRATIVE
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On 11/18/2022 @10:00 a.m., Licensing Program Analyst Patrick Ma, made an unannounced Case Management inspection to evaluate the circumstances surrounding a self-reported incident that occurred on 11/10/22 wherein a year 4 old child (C1) was left behind on the playground during transition.

During today's visit, LPAs spoke with Staff #1-2 and the Interim Director. The teachers who were involved at the time of the incident are on administrative leave during site visit and were not available for interview. According to the information obtained, 4 children were on the playground with previous staff 1 (PS1). While PS1 was still outside, communicated with previous staff 2 (PS2) at the playground doorway to bring in C1 and first aid backpack while she transitioned the other 3 children inside. PS2 stepped outside and brought in the first aid backpack only. Approximately 1-2 minutes after, Staff 3 (S3) heard and saw C1 crying outside and informed all the teacher in the classroom to bring C1 inside. C1 was returned inside the facility immediately by PS1.

See LIC 809D for deficiency cited.

LPA Patrick Ma informed facility representative Suong Le that this report dated 11/18/22 documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.
Also, LPA Ma informed the facility representative to provide a copy of this licensing report dated 11/18/22 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
Exit interview conducted and report was reviewed with the facility representative Suong Le. Notice of Site Visit was given and will be posted for 30 days.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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Document Has Been Signed on 11/18/2022 12:01 PM - It Cannot Be Edited


Created By: Patrick Ma On 11/18/2022 at 11:29 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: CAPSLO MIDLAND HEAD START
FACILITY NUMBER: 376700945

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Responsibility for Providing Care and Supervision: (1) No child(ren) shall be left without the supervision of a teacher at any time…Supervision shall include visual observation. This requirement was not met as evidenced by:
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Interm Director stated she will submit a plan that identifies how their standard transition plans works to eliminate children left behind during transition and now center willl stop partial transitions and incorporate Director for all transitions when available. Plan will be submitted by 11/18/22.
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Based on interview and records review, C1 was left behind on the playground during a transition into the classroom and discovered crying alone outside for approximately 1-2 minutes. This poses an immediate health and safety risk to 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:Renesha Askew
LICENSING EVALUATOR NAME:Patrick Ma
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
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