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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372000519
Report Date: 06/23/2021
Date Signed: 06/23/2021 01:15:52 PM

Document Has Been Signed on 06/23/2021 01:15 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:SANDY HILL NURSERY SCHOOLFACILITY NUMBER:
372000519
ADMINISTRATOR:SHANI WOODYFACILITY TYPE:
850
ADDRESS:1036 SOLANA DRIVETELEPHONE:
(858) 481-1378
CITY:SOLANA BEACHSTATE: CAZIP CODE:
92075
CAPACITY: 63TOTAL ENROLLED CHILDREN: 0CENSUS: 16DATE:
06/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Shani WoodyTIME COMPLETED:
01:30 PM
NARRATIVE
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On June 23, 2021 at 12:00 p.m. Licensing Program Analyst, Leilani Curtis, conducted an unannounced inspection to follow up on a self-reported incident that occurred on 6/7/21, wherein a 5 year old child (C1) fell off the climbing structure and broke her arm. LPA met with Director Shani Woody and proceeded to tour the facility. There were 16 children with 2 staff members present. Appropriate ratio/capacity were observed. Staff members have the required background clearances and are associated to the facility.

LPA interviewed Staff #1 (S1) and the Director. On 06/07/21 at approximately 1:30 p.m. C1 was climbing up the play structure when she fell landing on the sand below, injuring her right arm. Staff comforted the child and provided an ice pack for her arm. The parents of C1 were notified immediately and picked up the child. C1 was taken to the doctor and diagnosed with a broken arm which was placed in a cast. C1 returned to the facility on June 9, 2021. The play structure appears to be in good repair and is age appropriate. Underneath the structure is sand to absorb the impact of falls. At the time of the incident there were 6 children and 2 staff members present on the playground. Proper ratio and supervision were in place. The director states that staff constantly remind children of the playground rules. The facility responded appropriately.

Community Care Licensing was notified of the incident via telephone on 6/15/21. The Unusual Incident/Injury Report was received on 6/16/21. A report of the incident was not made to the Department by telephone or fax within the Department's next working day and during its normal business hours.

See LIC809D for cited deficiency

An exit interview was conducted with the director and appeal rights (LIC 9058 1/16) were discussed. The director’s signature on this form acknowledges receipt of these rights. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed the director post notice of site visit.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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Document Has Been Signed on 06/23/2021 01:15 PM - It Cannot Be Edited


Created By: Grace Curtis On 06/23/2021 at 12:49 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: SANDY HILL NURSERY SCHOOL
FACILITY NUMBER: 372000519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2021
Section Cited
CCR
101212(d)(1)(B)

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Reporting Requirements: (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. (1) Events reported shall include the following: (B) Any injury to any child that requires medical treatment. This requirement was not met as evidenced by:
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The director notified the department of the injury/incident via telephone on 6/15/21. The director understands that any injury to a child requiring medical treatment must be reported to the department within the department's next business day.
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Based on LPA interview's and the director's statement, the director did not notify the department of the child's injury/broken arm within the department's next business day. The incident occurred on 6/7/21 and the department was notified on 6/15/21. This poses a potential health and safety risk 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:Tashima Daniel
LICENSING EVALUATOR NAME:Grace Curtis
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


LIC809 (FAS) - (06/04)
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