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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701345
Report Date: 11/01/2024
Date Signed: 11/01/2024 06:02:08 PM

Document Has Been Signed on 11/01/2024 06:02 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:COASTAL CHRISTIAN ACADEMYFACILITY NUMBER:
376701345
ADMINISTRATOR/
DIRECTOR:		BIANCA QUESTFACILITY TYPE:
850
ADDRESS:4633 DOLIVA DRIVETELEPHONE:
(858) 598-6846
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 37TOTAL ENROLLED CHILDREN: 37CENSUS: 23DATE:
11/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Ashley MilburnTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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On 11/1/24 at 10:00 AM, Licensing Program Analysts (LPAs) Keturah Lane and Veronica Torres-Gonzalez conducted a case management visit to follow up on an unusual incident reported by the facility that occurred on 10/25/12. Upon arrival, LPAs met with Director Ashley Milburn and toured the facility. LPAs observed a total of 23 preschool children with four staff members plus the Director. Based upon record review and interview with Director, two of the staff were subs and were not associated to the facility.

Facility reported the incident via the duty line on Monday 10/28/24 and submitted the written incident report on 10/29/24. The incident report involved two children playing on the playground. One child (C1) was playing with a metal pie pan and was swinging it around and hit another child (C2) with it in the head causing an injury. Paramedics were called and child received medical treatment. Camera footage of the incident was not immediately available for LPA to observe but was requested.

During this visit, LPAs interviewed 4 children, 3 staff members and Director. LPAs also obtained copy of current facility roster, personnel roster, sign in/out sheet for 10/25/24 and staff timecards for 10/25/24. Based upon interviews with staff members and Director, it is determined that the metal pie plate in the playground was an immediate hazard and should have been removed from the playground as it had been an issue back in the summer months according to a staff member. Also, it was determined there was a lack of supervision during the incident as staff did not see the incident and had repeatedly asked the child to stopswinging the pie plate but did not take it away. There were two staff members on the playground with 15 children, but neither witnessed the incident.

(continued on LIC809-C...)
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: COASTAL CHRISTIAN ACADEMY
FACILITY NUMBER: 376701345
VISIT DATE: 11/01/2024
NARRATIVE
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LPA Keturah Lane informed facility representative DIrector Ashley Milburn that this report dated 11/1/24 documents 1 Type A citation which shall be posted for 30 consecutive days as there was an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Keturah Lane informed the facility representative to provide a copy of this licensing report dated 11/1/24 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

See LIC809D for two Type B citations.

Civil penalties were assessed in the amount of $200. Licensee was provided a copy of Civil Penalties Assessment LIC421BG.



Exit interview conducted and report was reviewed with the facility representative Ashley Milburn. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2024 06:02 PM - It Cannot Be Edited


Created By: Keturah Lane On 11/01/2024 at 04:57 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: COASTAL CHRISTIAN ACADEMY
FACILITY NUMBER: 376701345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2024
Section Cited
CCR
101239(m)(1)

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101239 Fixtures, Furniture, Equipment and Supplies (m) All play equipment and materials used by children shall be age-appropriate. (1) The licensee shall provide a variety of age-appropriate equipment, toys and materials in good condition...this requirement was not met as evidenced by....
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Director immediately removed and disposed of the metal pie plate and checked the playground for any additional hazards. Director stated she would also hold a staff meeting and provide agenda and signed staff attendance regarding training to identify and remove potential hazards in the classroom and playgrounds before children are present and e-mail it to LPA Lane by by the end of next week.
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Based upon staff interviews, the metal pie plate was not age-appropriate and had sharp edges and had been an issue previous to the reported incident and posed an immediate health, safety and personal rights risk to 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:Tashima Daniel
LICENSING EVALUATOR NAME:Keturah Lane
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2024 06:02 PM - It Cannot Be Edited


Created By: Keturah Lane On 11/01/2024 at 05:11 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: COASTAL CHRISTIAN ACADEMY
FACILITY NUMBER: 376701345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
101229(a)

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101229(a) Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. This requirement was not met as evidenced by...
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Director stated she would hold a training regarding visual supervision on the playground and provide agenda and sign in/out sheets to LPA Lane via e-mail by 11/8/24
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Based upon interviews with staff, staff did not see the incident that occurred when a child was hurt and did not remove the hazardous item in time to avoid the injury which poses a potential health, safety and personal rights risk to children in care.
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Type B
11/04/2024
Section Cited
CCR101170(e)(2)

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101170 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 101170(f)...this requirement was not met as evidenced by...
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Director stated she would associate both subs to the facility via Guardian or fax a LIC9182 for and ID for both to the SDNRO by 11/4/24 and double check on Guardian that they are associated to the facility. Director provided a written statement that she would associate all subs at the beginning of their work day going forward in Guardian.
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Based upon record review and Director statement, two subs were not associated to the facility which is a potential health, safety and personal rights risk to 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:Tashima Daniel
LICENSING EVALUATOR NAME:Keturah Lane
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


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