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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701506
Report Date: 05/10/2024
Date Signed: 05/10/2024 01:02:13 PM

Document Has Been Signed on 05/10/2024 01:02 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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:LEARNING JUNGLE ADAMS AVENUE - INFANTFACILITY NUMBER:
376701506
ADMINISTRATOR/
DIRECTOR:		XAVIER DEANFRASIOFACILITY TYPE:
830
ADDRESS:3844 ADAMS AVENUETELEPHONE:
(619) 301-7025
CITY:SAN DIEGOSTATE: CAZIP CODE:
92116
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 18DATE:
05/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Francisca LumabanTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 5/10/2024, at 11:00 a.m., Licensing Program Analyst (LPA) Adrian Castellon conducted an unannounced Case Management inspection to follow upon on the Unusual Incident reported to the Department on 5/3/2024. Upon arrival, LPA met with Assistant Director, Francisca Lumaban, and discussed the purpose of the inspection. LPA was led on a tour of the facility. There were 18 infants present and 6 staff during the inspection.

Based on interviews conducted and review of video footage of the incident, it was determined that on 5/3/2024, Child #1 left their classroom without the knowledge of the staff present in the class. On 5/3/24, there were five children present along with three staff members. Child was left unsupervised for approximately 4 minutes. Staff was speaking to a parent at the door of the classroom which was not shut. Child walked out of the classroom.

Per California Code of Regulations, (Title 22, division 12 & Chapter 1) one (1) Type A citation is being cited on the attached LIC 809-D.



LPA Castellon informed Assistant Director that this report dated 5/10/24 document(s) (1) Type A citation which shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Castellon informed the Assistant Director to provide a copy of this licensing report dated 5/10/24 that documents the 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.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Adrian Castellon
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: LEARNING JUNGLE ADAMS AVENUE - INFANT
FACILITY NUMBER: 376701506
VISIT DATE: 05/10/2024
NARRATIVE
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Incident was reported in a timely manner. Assistant director telephoned the Regional Office Duty Line on 5/3/24 and left a message requesting a call back. LIC624B was also submitted on the same date.

An exit interview was conducted with Assistant Director and a copy of this report along with the Appeals Rights (LIC 9058) will be provided not later than the following business day. A Notice of Site Visit is provided and required to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Adrian Castellon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 07/26/2024 04:43 PM


Created By: Adrian Castellon On 05/10/2024 at 12:22 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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: LEARNING JUNGLE ADAMS AVENUE - INFANT
FACILITY NUMBER: 376701506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2024
Section Cited
CCR
101429(a)(1)

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(a) In addition to Section 101229, the following shall apply: (1) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. This requirement was not met as evidenced by: Based on interviews conducted and video reviewed,
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All facility Staff will review regulation that has been cited and submit written statement acknowleding that regulation is understood. Statement must be submitted to the Regional Office by 5/17/24.

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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:Adrian Castellon
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
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