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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701231
Report Date: 05/13/2022
Date Signed: 05/13/2022 01:22:17 PM

Document Has Been Signed on 05/13/2022 01:22 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:ALPINE CHILDREN'S ACADEMYFACILITY NUMBER:
376701231
ADMINISTRATOR:STEPHANIE FREEMANFACILITY TYPE:
850
ADDRESS:2403 ALPINE BOULEVARDTELEPHONE:
(619) 445-5462
CITY:ALPINESTATE: CAZIP CODE:
91901
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 21DATE:
05/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Stephanie FreemanTIME COMPLETED:
01:30 PM
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On 05/13/2022 at 01:00 PM Licensing Program Analyst (LPA) Dana Stevens conducted a Case Management inspection as a result of deficiencies noted during a complaint inspection.

On 02/25/2022 at or around 5:30 PM a preschool child was injured when a school-age child threw a pillow at the preschool child and the younger child fell backward hitting his head on the carpeted floor. Director stated she was informed the following week that the child’s mother took the child for medical treatment. Neither Director nor Licensee reported the incident to the Licensing Department by phone or in writing within the required time frame.

The California Code of Regulations per Title 22, Section 102416.2(b)(3)(C) is being cited. Please refer to LIC 809-D for type-B deficiency cited.

Licensee will correct the deficiency by submitting an Unusual Incident Report to LPA within 7 days.

Exit interview was conducted and copy of this report and appeal rights were provided to Licensee. Notice of Site visit must be posted for 30 days.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Dana Stevens
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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 05/13/2022 01:22 PM - It Cannot Be Edited


Created By: Dana Stevens On 05/13/2022 at 12:50 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: ALPINE CHILDREN'S ACADEMY
FACILITY NUMBER: 376701231

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
101212(d)(1)(B)

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Reporting Requirements Upon the occurrence…of any of the events specified…below, a report shall be made to the Department by telephone or fax within the Department's next working day. Events reported shall include...Any injury to any child that requires medical treatment.This requirement was not met as evidenced by,
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Licensee shall submit a written Unusual Incident report (LIC 624) to Licensing within 7 days.
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Licensee did not submit a verbal or written report of the incident to Licensing department.
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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:Dana Stevens
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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