<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701088
Report Date: 09/28/2021
Date Signed: 09/28/2021 04:08:10 PM

Document Has Been Signed on 09/28/2021 04:08 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:SAY - JEFFERSON EXTENDED DAY PROGRAMFACILITY NUMBER:
376701088
ADMINISTRATOR:IRIZ STONEFACILITY TYPE:
840
ADDRESS:3770 UTAH STREETTELEPHONE:
(858) 380-8817
CITY:SAN DIEGOSTATE: CAZIP CODE:
92104
CAPACITY: 56TOTAL ENROLLED CHILDREN: 0CENSUS: 27DATE:
09/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Site Supervisor Sheila SkinnerTIME COMPLETED:
04:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/28/21, at 3:30PM, LPA, Luigi Gargaro, conducted an unannounced case management visit to the facility. Visit was conducted to deliver citation for violation of facility using classroom, room 208, that was not previously inspected and approved by Licensing. Analyst was not able to issue citation at time of previous 08/31/21 visit but issued it during today's return visit to address the violation. The classroom has otherwise been found to appropriately furnished and accommodated and has been approved for use. Analyst had Site Supervisor Skinner sign today's report and then printed a copy of it and facility appeal rights for her records.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Luigi Gargaro
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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 2
Document Has Been Signed on 09/28/2021 04:08 PM - It Cannot Be Edited


Created By: Luigi Gargaro On 09/28/2021 at 03:05 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: SAY - JEFFERSON EXTENDED DAY PROGRAM
FACILITY NUMBER: 376701088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2021
Section Cited
CCR
101173(c)

1
2
3
4
5
6
7
101173 Plan Of Operation (c) Any proposed changes in the plan of operation that affect services to children shall be subject to departmental approval prior to implementation and shall be reported as specified in Section 101212. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Classroom was approved after the completion of the 08/31/21 inspection but site supervisor and program director understand that licensing is to be informed of any potential changes in operations at the facility and must receive their approval prior to them occurring
8
9
10
11
12
13
14
Based on analyst observation, during 08/31/21 case management visit, program had started using classroom 208 prior to it being inspected and approved by the department. Making changes to the operation of a facility prior to advising licensing and obtaining their approval is a potential risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Jason Garay
LICENSING EVALUATOR NAME:Luigi Gargaro
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2