Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700083
Report Date: 11/05/2015
Date Signed: 11/05/2015 03:55:03 PM

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:CARLSBAD EDUCATIONAL FOUNDATION-AVIARA OAKS ELEM.FACILITY NUMBER:
376700083
ADMINISTRATOR:SCHWARTZ, ASHLEYFACILITY TYPE:
840
ADDRESS:6900 AMBROSIA LANETELEPHONE:
(760) 331-6028
CITY:CARLSBADSTATE: CAZIP CODE:
92011
CAPACITY:110CENSUS: DATE:
11/05/2015
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Director Ashley SchwartzTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst, Joelle Redding, made an unannounced case management visit to evaluate the circumstances surrounding a self reported incident that occurred on 10/26/15 wherein a 5 year old child fell from the monkey bars, sustaining a wrist fracture.

LPA interviewed Director, staff that were present that afternoon and the two children involved. There were approximately 30 children on the playground at that time with 4-5 staff members present. However, there was no staff close to the monkey bars and there was no visual supervision of the activity. The injured child approached playground staff and indicated that he had been pulled from the monkey bars by another 5 year old child. Staff spoke to both children, the injured child indicating he had been pulled and the other child indicating that he had been helping. Facility staff responded appropriately and provided first aid, evaluated the wrist then called the parent for pick up. Information obtained today supports the probability that staff were not dispersed adequately enough to have a visual of all the children on the playground at the time of the incident and that it could have been prevented.

See LIC 809D for deficiency.

Note: Per Assembly Bill 633 (Parent Notification Requirements) the facility is to provide a copy of this Licensing Report to the parents of all children currently in care as well as any children newly enrolled over the next 12 month period. Parents are to sign form LIC 9224, Acknowledgment of Receipt of Licensing Reports and the form is to be kept in each child's file for Licensing's review. In addition, this Licensing report is to be posted along with the Notice of Site Visit for 30 days.
SUPERVISOR'S NAME: Carl SheltonTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Joelle ReddingTELEPHONE: (619) 767-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2015
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: CARLSBAD EDUCATIONAL FOUNDATION-AVIARA OAKS ELEM.
FACILITY NUMBER: 376700083
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2015
Section Cited
101229(a)(1)
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Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time.

A 5 year old child fell or was pulled from the monkey bars, fracturing his wrist, and the incident was unobserved by staff.
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Site Director will provide the report to Program Director Jose de Anda. A staff meeting will be conducted to address proper placement of staff on the playground and the definition and importance of "visual supervision" at all times. The roster and agenda for the meeting will be sent to Licensing for verification by 11/13/15
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Lack of visual supervision creates an immediate hazard 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: Carl SheltonTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Joelle ReddingTELEPHONE: (619) 767-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2015
LIC809 (FAS) - (06/04)
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