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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701365
Report Date: 09/08/2021
Date Signed: 09/08/2021 11:54:30 AM

Document Has Been Signed on 09/08/2021 11:54 AM - 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:LA PETITE ETOILE 360 PRESCHOOLFACILITY NUMBER:
376701365
ADMINISTRATOR:ALEJANDRA NORMA DIAZFACILITY TYPE:
850
ADDRESS:4555 PARK BOULEVARDTELEPHONE:
(858) 449-4891
CITY:SAN DIEGOSTATE: CAZIP CODE:
92116
CAPACITY: 20TOTAL ENROLLED CHILDREN: 0CENSUS: 17DATE:
09/08/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Celine TheanoTIME COMPLETED:
12:00 PM
NARRATIVE
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On 9/8/2021 at 9:45am, Licensing Program Analyst (LPA), Martha Malane conducted an unannounced Plan of Correction (POC) inspection at the facility. Purpose of this inspection is to ensure citations issued during an annual inspection dated 8/25/2021 were corrected. Upon arrival, LPA met with Teacher, Jennifer Nelson and proceeded to tour the facility. At 10:00am, Licensee, Celine Theano arrived at the facility

Citations issued on 8/25/21 were corrected as follows:

There were 17 children with three (3) qualified teachers during today’s inspection. LPA observed staffing/ratio and capacity to be within the limitations set forth on the license.

· LPA reviewed criminal record clearance for S3 and confirmed a criminal background clearance transfer request was submitted to CCL and S3 is associated to this facility.

· Personnel records were reviewed and show proof of enrollment in required courses to meet teacher qualifications for S4. Transcripts provided for S3 show proof of completion of required courses to meet teacher qualifications.

· Personnel records for S1 confirm a health screening and negative tuberculosis test were submitted.

Licensee did not ensure proper handling and storage of medications was observed as consent form for C2 was not submitted by the parent and medication for C3 was not in the original container or with a prescription label.

See continuation LIC809C
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: LA PETITE ETOILE 360 PRESCHOOL
FACILITY NUMBER: 376701365
VISIT DATE: 09/08/2021
NARRATIVE
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Licensee, Celine Theano requested an extension to report the name of the child care center director. This correction was not made during today’s inspection. Licensee stated she will submit the name of the director and completed paperwork to CCL by 9/13/21.

Four (4) of the deficiencies cited on 8/25/21 have been cleared see 809D deficiency page for deficiency being recited as a plan for proper handling and storage of medication was submitted to CCL, however licensee did not ensure medication was properly handled and stored. One citation was granted an extension which is due on 9/13/21.

LPA provided Licensee, Celine Theano with the Notice of Site Visit – LIC 9213, which is to be posted for thirty (30) days. LPA observed form LIC 9213 posted on the bulletin board at the entrance. An exit interview was conducted with the licensee, who was provided a copy of their Licensee Rights (LIC 9058 1/16). Their signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 11/15/2021 01:24 PM


Created By: Martha Malane On 09/08/2021 at 11:32 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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: LA PETITE ETOILE 360 PRESCHOOL
FACILITY NUMBER: 376701365

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2021
Section Cited
CCR
101226(e)(3)(A)

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101226(e)(3)(A)HealthRelated Services(e)In centers where the licensee chooses to handle medications:(3)Prescription medications may be administered if all of the following conditions are met: (A)…shall be administered in accordance with the label directions…This requirement was not met as evidenced by:
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Licensee stated she will send proof that medication for C1 is in its original container with a prescription and a consent form submitted by the parent of C2 by 9/13/2021.
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Based on LPA observation and records review licensee did not ensure medication was properly handled and stored as medication for C1 was not in its original container with prescription which poses a potential risk to the health and safety to children in care. This is an amended version of the report dated 9/8/2021.
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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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
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