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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701138
Report Date: 02/08/2023
Date Signed: 02/08/2023 01:25:58 PM


Document Has Been Signed on 02/08/2023 01:25 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:DOT TO DOTFACILITY NUMBER:
376701138
ADMINISTRATOR:CASSANDRA GOLDSTEINFACILITY TYPE:
850
ADDRESS:12160 ALTA CARMEL COURTTELEPHONE:
(858) 485-1978
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:56CENSUS: 46DATE:
02/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Cassandra Goldstein and Sasha StarosadchevaTIME COMPLETED:
01:35 PM
NARRATIVE
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On 2/08/2023 at 10:50am, Licensing Program Analyst (LPA) Selina Siao conducted an unannounced case management visit to follow-up on a self reported incident regarding an injury incident that happened on 1/30/2023 around 10:15am where a child had to seek medical care. Upon arrival, LPA met with Core Facilitator Sasha Starosadcheva who was at the front lobby area. Four classrooms were toured and appropriate ratios were observed. All staff members present has the required background clearances and are associated to the facility.

The facility submitted the written incident report to the Licensing office within the seven days requirement on 02/07/2023 but facility failed to report the incident to the department within the required 24 hours. On 1/30/2023, while at the playground, the injured child went up to her teacher to show that the a piece of small wood chip had went through her shirt and was sticking out of her chest area. Staff members stated that the child did not cry when the incident happened and she didn't cry until the parent arrived to take her to the doctor. Per information obtained, there were 12 children supervised by one teacher as the other staff was on a break. During today's inspection, LPA conducted interviews with the teacher that was supervising the children at the playground, Director and Core Facilitator that has knowledge of the incident. LPA obtained a picture of the child's injury from the facility along with the child's confidential information. Per the child's teacher and other staff members, it is unsure how the incident happened but based on information gathered by staff, the wood chip is most likely from the wooden dome shape climbing structure. After the incident, the sand dome area and other nature wood area was reinspected and all chipping pieces were removed to be replace. LPA inspected the playground today and photos of the playground was taken. The playground needs additional cushioning under and around all high climbing structures.

SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: DOT TO DOT
FACILITY NUMBER: 376701138
VISIT DATE: 02/08/2023
NARRATIVE
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Based on information obtained, the facility took prompt action by bringing the child into the office to assess the wound to ensure that the area is kept clean and free of dirt and notifying the child's parent immediately to take the child to the doctor. The child was taken to the doctor and the wood chip was safely removed from the child's chest as it was deep under the skin. The parent kept the child home for one day and the child returned to care on 2/1/2023.

See LIC809D for citations issue. Exit interview conducted with the director and core facilitator. Notice of site visit was posted and it must remain posted for 30 days.

SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/08/2023 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108


FACILITY NAME: DOT TO DOT
FACILITY NUMBER: 376701138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2023
Section Cited

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Reporting Requirements:
Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, 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.
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Director stated that they will have a staff meeting and training to review the regulation on reporting requirements and review the licensing LIC624 unusal incident form with staff members on 2/24/2023.
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This requirement is not met as facility did not report the unusual incident to the department within the next business day. This poses a potential health and safety risk to clients in care.
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Facility will submit the agenda along with the staff member's sign in sheet to Licensing no later than 3/01/2023.
Type B
03/07/2023
Section Cited

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Outdoor Activity Space:
As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls.
(1) Sand, woodchips and peagravel,or rubber mats commercially produced for the purposes of (e) above, are permitted.
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Director stated that they will order additional sand and/or wood chips for the playground. The children will not use the rope as a swing and climb on the dome shape structure until there are sufficient cushioning.
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This requirement is not met. The rope swing area, yellow slides area and the doam climbing structures area does not have sufficient cushioning that absorbs falls. This poses a potential health and safety risk to clients in care.
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Director will review the regulation on outdoor activity space with staff members on 2/24/2023 and will submit a copy of the agenda along with the staff member's sign in sheet to Licensing by 3/1/2023. Proof of purchases of the sand and wood chips for the playground along with pictures showing that the playground has sufficient cushioning shall be submit to Licensing by 03/07/2023.
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: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
LIC809 (FAS) - (06/04)
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