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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370806459
Report Date: 04/22/2025
Date Signed: 04/22/2025 02:04:34 PM

Document Has Been Signed on 04/22/2025 02:04 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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:V.I.P. VILLAGE - STATE PRESCHOOLFACILITY NUMBER:
370806459
ADMINISTRATOR/
DIRECTOR:		DAVID SHEPPARDFACILITY TYPE:
850
ADDRESS:1001 FERN AVENUETELEPHONE:
(619) 628-8690
CITY:IMPERIAL BEACHSTATE: CAZIP CODE:
91932
CAPACITY: 246TOTAL ENROLLED CHILDREN: 246CENSUS: 117DATE:
04/22/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Michelle SyversonTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On 04/22/2025, at 8:45 am., Licensing Program Analysts (LPAs) Oscar Picazo and Vicky Williamson conducted an unannounced case management inspection to follow up on a self-reported incident. LPAs met with Facility Representative, Michelle Syverson. LPAs discussed the purpose of the inspection and were led on a tour of the indoor and outdoor of the facility. There were 117 children present with 27 staff members.

On 04/17/2025, the Facility Representative reported an incident regarding absence of supervision of Child #1 (C1). Per the Facility Representative, the incident occurred on 04/16/2025, at about 3:05pm outside of classroom 16. Facility Representative stated that there were 13 children with one teacher and one instructional assistant present inside of the classroom.

Interviews were conducted with the Facility Representative and Staff #1 (S1). C1 was not available for interview during time of inspection. LPA obtained a copy of the facility roster and sign in/ sign out sheets. Staff files were reviewed. LPAs inspected the area outside of classroom 16 where the incident occurred. LPA's also reviewed video footage.

S1 stated that there were 14 children present inside of the classroom and 13 children transitioned to the playground with her. S1 stated that Staff #2 (S2) remained inside of the classroom assisting another child. S1 stated that while in transition from classroom 16 to the playground, she was unaware that C1 left the line of children that were transitioning to the playground. S1 acknowledged that she did not conduct a head count of the children upon arrival to the playground.

See LIC 809C Continuation...
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Oscar Picazo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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 4
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)
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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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: V.I.P. VILLAGE - STATE PRESCHOOL
FACILITY NUMBER: 370806459
VISIT DATE: 04/22/2025
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Facility Representative stated that a review of video footage revealed that C1 left the line of children transitioning to the playground with the teacher and followed an authorized representative for another daycare child to the office. Facility Representative stated that C1 was brought to the office by the authorized representative and that she and the school psychologist walked C1 the to the playground to locate S1. Facility Representative stated that C1's authorized representative was contacted immediately.

Facility Representative stated that she has changed the recess schedule for classroom 16 from 3:00pm to 2:00pm to avoid the dismissal procedures with classroom 15. Facility Representative and S1 stated that name to face procedures have been implemented.

A review of video footage provided evidence that C1 was left without supervision outside of classroom 16 for less than 1 minute.

Based on interviews and LPAs review of video footage it has been determined that C1 was left without supervision outside for less than 1 minute. One (1) Type A deficiency of California Code of Regulations, Title 22, Division 12, Chapter 1, is being cited on the attached LIC 809D.

LPAs informed Facility Representative, Michelle Syverson that this report dated 4/22/2025 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, LPAs informed Facility Representative, Michelle Syverson to provide a copy of this licensing report dated 4/22/2025 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. LPAs provided Facility Representative, Michelle Syverson with form LIC 9224.

A Notice of Site Visit (LIC 9213) was given to Facility Representative, Michelle Syverson 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, Michelle Syverson
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Oscar Picazo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/22/2025 02:04 PM - It Cannot Be Edited


Created By: Oscar Picazo On 04/22/2025 at 01:09 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: V.I.P. VILLAGE - STATE PRESCHOOL
FACILITY NUMBER: 370806459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2025
Section Cited
CCR
101229(a)(1)

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The licensee shall provide care and supervision... No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation.
This requirement is met as evidence by:
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Facility Representative stated that she will conduct a training with staff on supervision and transitioning of children. Facility Representative will submit a staff sign in sheet and a written plan detailing new transitioning and supervision procedures and submit to the SDRO by 4/23/2025.
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Based on interview and record review, the licensee did not comply with the section cited above in that it was determined that on 4/16/25, there was an absence of supervision resulting in C1 being left unsupervised which poses an immediate, safety, or personal rights risk to persons 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.
Tulam Vu
NAME OF LICENSING PROGRAM MANAGER:
Oscar Picazo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
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