<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 130805337
Report Date: 04/08/2025
Date Signed: 04/08/2025 05:41:26 PM

Document Has Been Signed on 04/08/2025 05:41 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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CHRISTIAN CHILD CARE CENTER / PRESCHOOLFACILITY NUMBER:
130805337
ADMINISTRATOR/
DIRECTOR:
TANYA HERNANDEZFACILITY TYPE:
850
ADDRESS:450 SOUTH WATERMAN AVENUETELEPHONE:
(760) 352-6703
CITY:EL CENTROSTATE: CAZIP CODE:
92243
CAPACITY: 81TOTAL ENROLLED CHILDREN: 93CENSUS: 71DATE:
04/08/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Elizabeth Veliz TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/8/2025, at 10:20am, Licensing Program Analysts (LPAs) Vicky Williamson and Jacqueline Macias conducted an unannounced annual random inspection. LPAs met with Facility Representative, Elizabeth Veliz and disclosed the purpose of the inspection. LPAs accompanied by Facility Representative toured the indoor and outdoor of the facility. This is a full day program which operates all year. Days and hours of operation are Monday - Friday from 7:30am -5:30pm. There are currently seven (7) classrooms in operation. There were 71 children present with 10 teachers and two aides.

Furniture and equipment are in good condition. Floors in the facility are clean and safe. Disinfectants, cleaning solutions, medications and other hazardous items were accessible to children during time of inspection. LPAs observed the following items accessible to children: 3 pair of teacher scissors in an unlocked drawer in Room #12, two bottles of medication on the counter top, a screw driver in an unlocked drawer and a blade in an unlocked cabinet in Room #14. Facility Representative removed the hazardous items to a secure storage during to time of inspection. All kitchen, food preparation and storage areas are clean, free of litter/rubbish and free of rodents. Solid waste storage containers have tight fitting covers and are in good repair. The surface of the outdoor activity space is maintained in a safe condition and free of hazards. Playground equipment is in safe condition. Areas around high climbing equipment, swings and slides have cushioning to absorb falls. Shade in the outdoor area is provided by shade canopies.

Facility has smoke and carbon monoxide detectors that meet statutory requirements. There was no documentation for disaster drills available for review during the time of inspection.

See LIC 809C Continuation...
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Vicky Williamson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CHRISTIAN CHILD CARE CENTER / PRESCHOOL
FACILITY NUMBER: 130805337
VISIT DATE: 04/08/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility Representative stated there are no swimming pools or other bodies of water on the premises. Facility Representative stated there are no firearms or ammunition allowed or stored on the premises

The facility provides morning and afternoon snack. Parent provide lunch for the children. Menus are posted weekly. Filtered drinking water is available both indoors and outdoors. The facility provides paper cups and children also bring their own water bottles.

Facility Representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Capacity and limitations as specified on the license are being maintained. Children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than twelve (12) children in care.

At least one person trained in CPR and Pediatric First Aid is present when children are at the facility. The name of the facility representative and the fully qualified teacher designated to act in the facility representative’s absence has been reported to the Department. LPAs reviewed facility sign in /sign out sheets. Facility Representative was reminded that the person who signs the child in and out of the facility shall use their full legal signature and record the time of day.

LPAs reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment. LPAs reviewed a sample of staff files and observed files were incomplete. Staff #1 did not have Tuberculosis clearance, immunization records for influenza, pertussis and measles, and health screening available for review. Current documentation of completed mandated reporter training was not available for review for 12 staff members.

See LIC 809C Continuation...
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Vicky Williamson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CHRISTIAN CHILD CARE CENTER / PRESCHOOL
FACILITY NUMBER: 130805337
VISIT DATE: 04/08/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/


Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed - related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

LPAs discussed and provided facility representative with the following: childcare advocates email address: childcareadvocatesprogram@dss.ca.gov. In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.


Please visit the Guardian web page and set-up your Guardian account. https://cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian If you have any questions regarding Guardian, please contact CDSS at email: guardian@dss.ca.gov

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

LPAs verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. See LIC 809C Continuation...
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Vicky Williamson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CHRISTIAN CHILD CARE CENTER / PRESCHOOL
FACILITY NUMBER: 130805337
VISIT DATE: 04/08/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Per California Code of Regulations, Title 22, Division 12, Chapter 1, One (1) Type A and five (5) Type B deficiencies are being cited on the attached LIC 809D.


LPA informed Facility Representative, Elizabeth Veliz that this report dated 4/8/2025 documents one (1) Type A citation, which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed Facility Representative, Elizabeth Veliz to provide a copy of this licensing report dated 4/8/2025 that documents a 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. LPA provided Facility Representative, Elizabeth Veliz with form LIC 9224.

A Notice of Site Visit (LIC 9213) was given to Facility Representative, Elizabeth Veliz and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. LPAs observed LIC 9213 was posted. Appeal Rights (LIC 9058) was provided. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.



An exit interview was conducted, and the report was reviewed with the Facility Representative, Elizabeth Veliz.
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Vicky Williamson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 04/08/2025 05:41 PM - It Cannot Be Edited


Created By: Vicky Williamson On 04/08/2025 at 03:17 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: CHRISTIAN CHILD CARE CENTER / PRESCHOOL

FACILITY NUMBER: 130805337

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in that medications and other hazardous items were observed on a countertop, in unlock drawers and cabinets accessible to children in Room #12 and Room #14 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2025
Plan of Correction
1
2
3
4
Facility Representative removed the items to a secure storage during the time of inspection. Facility Representative stated that she will provide a plan to the Department detailing how staff will ensure that medications and other hazardous items will be made inaccessible to children. Facility Representative will provide a plan to the SDRO, no later than 4/25/25.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tulam Vu
NAME OF LICENSING PROGRAM MANAGER:
Vicky Williamson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 04/08/2025 05:41 PM - It Cannot Be Edited


Created By: Vicky Williamson On 04/08/2025 at 03:17 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: CHRISTIAN CHILD CARE CENTER / PRESCHOOL

FACILITY NUMBER: 130805337

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in that documentation of disasters drills were not available for review during time of inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
1
2
3
4
Facility Representative stated that she will conduct and document disasters drills and provide proof to the SDRO, no later than 4/11/25.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in that 12 staff did not have current mandated reporter training documentation available for review during time of inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
1
2
3
4
Facility Representative stated that she will ensure that staff complete the mandated reporter training and provide proof to the SDRO, no later than 4/25/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tulam Vu
NAME OF LICENSING PROGRAM MANAGER:
Vicky Williamson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 04/08/2025 05:41 PM - It Cannot Be Edited


Created By: Vicky Williamson On 04/08/2025 at 03:17 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: CHRISTIAN CHILD CARE CENTER / PRESCHOOL

FACILITY NUMBER: 130805337

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in that immunization records for Staff #1 were not available for review during time of inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
1
2
3
4
Facility Representative stated that she will ensure that proof of immunization records for Staff #1 are provided to the SDRO, no later than 4/25/2025.
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in that a health screening report for Staff #1 was not available for review during time of inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
1
2
3
4
Facility Representative stated that she will ensure that proof of health screening report for Staff #1 is provided to the SDRO, no later than 4/25/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tulam Vu
NAME OF LICENSING PROGRAM MANAGER:
Vicky Williamson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 04/08/2025 05:41 PM - It Cannot Be Edited


Created By: Vicky Williamson On 04/08/2025 at 03:17 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: CHRISTIAN CHILD CARE CENTER / PRESCHOOL

FACILITY NUMBER: 130805337

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in that a Tuberculosis clearance for Staff #1 was not available for review during time of inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
1
2
3
4
Facility Representative stated that she will ensure that proof of Tuberculosis clearance of Staff #1 is provided to the SDRO, no later than 4/25/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tulam Vu
NAME OF LICENSING PROGRAM MANAGER:
Vicky Williamson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 9 of 9