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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701246
Report Date: 08/20/2021
Date Signed: 08/20/2021 01:59:13 PM

Document Has Been Signed on 08/20/2021 01:59 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:OCEANSIDE SHINING STARS PRESCHOOLFACILITY NUMBER:
376701246
ADMINISTRATOR:CHRISTINA CRUZFACILITY TYPE:
850
ADDRESS:1122 SOUTH COAST HIGHWAYTELEPHONE:
(760) 435-0713
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 28TOTAL ENROLLED CHILDREN: 0CENSUS: 19DATE:
08/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH: Director Mckenna ShiverTIME COMPLETED:
02:07 PM
NARRATIVE
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 LPA arrived at the facility to conduct a case management visit and conducted a COVID-19 prescreening prior to entry.

During the course of a complaint investigation control number 10-CC-20210611145340 , LPA verified that an Unusual incident occurred on or around 6/9/21 which was not communicated to Community Care Licensing (CCLD) by phone within 24 hours of the incident occurring nor was an Unusual Incident Report (LIC624) form filed within 7 days as required by Title 22 .

Although parents were notified of an incident, the Director did not call or notify licensing until Complaint investigation was initiated, therefore California Code of Regulations Title 22, Division & Chapter number 101212(d) are being cited on the attached LIC 809D. This poses a potential health and safety risk to the children in care.

LPA reviewed LIC624 form in detail with Director and Licensee on this date.

An exit interview was conducted and appeal rights were discussed with Director (Mckenna Shiver) and Licensee Shams Nassar and Notice of Site visit given. LPA observed posting
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Otsanya Cameron
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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 08/20/2021 01:59 PM - It Cannot Be Edited


Created By: Otsanya Cameron On 08/20/2021 at 11:03 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: OCEANSIDE SHINING STARS PRESCHOOL
FACILITY NUMBER: 376701246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2021
Section Cited
CCR
101212(d)(1)(B)

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Reporting Requirements: … a report shall be made to the Dept. by telephone or fax within the Dept's next working day and during its normal business hours....a written report....shall be submitted to the Dept. within 7 days following the occurrence of such event. This requirement was not met as evidenced by:
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Directors states will conduct training on 8/23/21 that will discuss reporting requirements, UIRS, and what constitutes as an incident.
Director will provide proof of correction by POC date.
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During investigation of complaint it was found that licensee did not ensure an incident was reported to the depatment.
This poses a potential risk 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:Pauline Beschorner
LICENSING EVALUATOR NAME:Otsanya Cameron
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021


LIC809 (FAS) - (06/04)
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