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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372005150
Report Date: 05/19/2022
Date Signed: 05/19/2022 12:41:53 PM

Document Has Been Signed on 05/19/2022 12:41 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:PALOMAR COMMUNITY COLLEGE DISTRICT ECE LAB SCHOOLFACILITY NUMBER:
372005150
ADMINISTRATOR:TAMARA HOLTHAUSFACILITY TYPE:
850
ADDRESS:1140 WEST MISSION ROADTELEPHONE:
(760) 744-1150
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 108TOTAL ENROLLED CHILDREN: 108CENSUS: 70DATE:
05/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Tamara HolthausTIME COMPLETED:
01:00 PM
NARRATIVE
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On May 19, 2022 at 9:30 a.m. Licensing Program Analyst, Leilani Curtis, conducted an unannounced inspection to follow up on a self-reported incident that occurred on 5/5/22, wherein a 4-year-old child (C1) tripped on the playground and bumped his head on the end of the playground tunnel. LPA met with Director Tamara Holthaus and proceeded to tour the facility. There were 70 children with 14 staff members present. Appropriate ratio/capacity were observed. LPA observed staff member Martha Cortes Rodriguez working with children. Ms. Cortes Rodriguez is fingerprint cleared but is not associated to the facility. The director states that Ms. Cortes Rodriguez worked at the Escondido location of Palomar Community College District ECE Lab School and has been at this facility for two years. The other staff members have the required background clearances and are associated to the facility.

LPA interviewed the director and staff #1 (S1). C1 was not present at the facility at the time of inspection. On 5/5/22 at approximately 4:56 p.m. C1 was running on the playground with four children towards the playground tunnel when he tripped, fell and bumped his head on the right end of the tunnel. The child obtained an abrasion on his forehead. S1 observed the incident and comforted the child. Staff cleaned the injury and applied an ice pack. The parents of C1 were immediately notified of the incident and head injury. C1 was taken to urgent care where he was examined. No follow up treatment was needed. At the time of the incident there were 7 children on the playground being supervised by one staff member. Appropriate ratio/supervision was in place. LPA toured the playground and observed it to be free from hazards. The tunnel that C1 hit his head on is made of concrete and sits on turf.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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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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: PALOMAR COMMUNITY COLLEGE DISTRICT ECE LAB SCHOOL
FACILITY NUMBER: 372005150
VISIT DATE: 05/19/2022
NARRATIVE
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Prior to this incident, on 3/4/22, the director notified Community Care Licensing of a previous incident on the playground wherein another 4-year-old child (C2) tripped on the playground and fractured his elbow. This incident occurred on 2/25/22 at approximately 10:05 a.m. LPA interviewed staff #2 and child #2 (C2) about the incident. C2 was running on the playground with a group of children from the sandbox towards the grass when he tripped over a rock and landed on his hands. S2 observed the incident and comforted the child. Another staff member (S3) obtained ice and applied it to his right elbow. The parents of C2 were immediately notified and C2 was taken to urgent care where he was treated for a fractured elbow. At the time of the incident there were 12 children on the playground being supervised by one staff member. Appropriate ratio/supervision was in place. The staff members responded appropriately to both incidents and the parents were notified timely

As a result of the injuries the director spoke to the staff members about active supervision. The staff members reminded the children about playground safety. The director states that they will continue to encourage the children to watch where they are running and the facility staff will continue to check the playgrounds daily for any safety hazards. The staff will continue to provide constant visual supervision. The director will discuss active supervision and playground safety with staff again at their next staff meeting which will be held on 6/7/22.

Please see LIC809D for cited deficiency. A civil penalty has been assessed.

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: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2022 12:41 PM - It Cannot Be Edited


Created By: Grace Curtis On 05/19/2022 at 12:01 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: PALOMAR COMMUNITY COLLEGE DISTRICT ECE LAB SCHOOL
FACILITY NUMBER: 372005150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
101170(e)(2)

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101170(e)(2) Criminal Record Clearance:(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 101170(f)...This requirement was not met as evidenced by:
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The director states that she will submit a request to have Ms. Cortes Rodriguez associated to the facility today, 5/20/22. The director will send LPA verification that the transfer request has been made via email by 5/20/22.
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Based on record review, staff member Martha Cortes Rodriguez is fingerprint cleared but is not associated to the facility. This poses a potential health and safety risk to the 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: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022


LIC809 (FAS) - (06/04)
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