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13 | On 8/2/22 @ 11:45 a.m., Licensing Program Analyst (LPA) Joelle Redding made an unannounced visit to deliver findings on the above-referenced allegations.
During this investigation, LPA conducted several interviews, observed the facility and reviewed relevant documentation. Based on the information above, the facility has not been reporting positive cases of Covid 19 to Licensing, an Aide has been left alone with awake children, without the direct supervision of a fully qualified staff, for a short period of time on one or more occasions, and the last emergency drill was conducted in September of 2021, more than 9 months ago.
Based on LPA’s observations and interviews, and review of relevant documentation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED, California Code of Regulationsre being cited on the attached LIC 9099D. |
| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/30/2022
Section Cited
CCR
101212(d)(1((C) | 1
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7 | Reporting Requirements. Upon the occurrence...a report shall be made to the Department...next working day...In addition, a written report shall be submitted to the Department within seven days...Any unusual incident...that threatens the physical or emotional health or safety of | 1
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7 | Director states that she has been reporting to parents and guardians as well as to Department of Public Health and following guidelines provided. She was unaware of the requirement to report each case to Licensing as well. She states she has since corrected the procedures to ensure that each positive Covid case is reported to Licensing as well. |
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14 | any child. This requirement was not met as evidenced by:
Based on interview with the Director, the facility had not been reporting positive cases of Covid to Licensing per regulation. This is a potential risk to the health and safety of children in care. | 8
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Type B
08/30/2022
Section Cited
CCR
101216.2(e) | 1
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7 | Teacher Aide Qualifications and Duties. An aide shall work only under the direct supervision of a teacher.
This requirement was not met as evidenced by: | 1
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7 | Director states that she believes that on those occasions, the lead staff may have been taking a bathroom break and wasn't aware that the Aide was not to be left alone with the children. Director states that a staff meeting will be conducted during the week of the 26h and she will readdress ratios and qualifications. A roster and agenda will be sent to Licensing |
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14 | Based on interviews, Staff #15, has been left alone with awake children, for a short period of time without the direct supervision of a fully qualified staff on one or more occasions. This is a potential risk to the health and safety of children in care. | 8
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14 | as verification of correction. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/16/2022
Section Cited
CCR
101174(d) | 1
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7 | Disaster and Mass Casualty Plan. Disaster drills shall be conducted at least every six months.
This requirement was not met as evidenced by: | 1
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7 | Director stated that due to Covid, she was reluctant to mix cohorts and therefore, delayed the emergency drills. However, upon Licensing's visit on 7/11, an emergency drill was conducted on 7/13 at 9:30 a.m. and she will ensure to continue to meet regulatory requirements of once every six months and keep a log for verification. |
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14 | Based on interviews with the Director, an emergency disaster drill has not been conducted since September of 2021. This is a potential risk to the health and safety of children in care. | 8
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