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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701520
Report Date: 08/11/2022
Date Signed: 08/11/2022 01:20:26 PM

Document Has Been Signed on 08/11/2022 01:20 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:COZY CUBS 2 - INFANTFACILITY NUMBER:
376701520
ADMINISTRATOR:VIRGINIA ANDRADEFACILITY TYPE:
830
ADDRESS:4351 PARKS AVETELEPHONE:
(619) 460-6432
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
08/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Virginia "Ginny" Andrade, Facility DirectorTIME COMPLETED:
01:20 PM
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On August 11, 2022, at 12:20 PM, Licensing Program Analyst (LPA), Marie Hernandez, conducted an unannounced Case Management Inspection to deliver the incident review findings of 07/12/2022 due to an incident with child #1. On 07/12/2022, the Department received the incident report from the facility pertaining to child #1. LPA met with the Facility Director, Virginia Andrade, The facility reported that on 07/11/2022 at 5:07 PM, child #1 fell and hit his forehead on the tile floor causing a slight nosebleed and a wound above the right eyebrow. The parent was contacted and took child to the doctor's. The child received fours stitches to the wound.

Through the course of the incident review, LPA conducted several interviews with the staff and child 's parent. The child could not be interviewed as child is nonverbal. The Director stated she immediately tended to child's needs, cleaned and iced the wound. The staff person stated at time of incident, there were two children with her (staff person) in the classroom. The staff person stated she observed child #1 crawling away towards the low to ground baby swing and child trying to climb into the baby swing. The staff person stated she tried to prevent the child from climbing into the baby swing but the child was quick and she (staff person) was unable to prevent the child from falling. Child #1 fell and hit his forehead on the floor. The child sustained a nosebleed and wound to the right eyebrow. The staff person stated she attempted to prevent the child's injury but child was too quick. LPA inspected the classroom and the baby swings for safety hazards. However, due to conflicting information obtained, the incident could not be determined whether it was a lack of supervision or a safety issue. At time of incident, the facility director removed the baby swing from the classroom.

An exit interview was conducted and the report was provided to the Facility Director, Virginia "Ginny" Andrade. The Notice of Site Visit was provided and posted during the visit.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Marie Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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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