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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600278
Report Date: 10/27/2022
Date Signed: 10/27/2022 01:20:43 PM

Document Has Been Signed on 10/27/2022 01:20 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:MAAC GOSNELLFACILITY NUMBER:
376600278
ADMINISTRATOR:SARA GIBBSFACILITY TYPE:
850
ADDRESS:139 GOSNELL WAYTELEPHONE:
(760) 736-3066
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 112TOTAL ENROLLED CHILDREN: 82CENSUS: 55DATE:
10/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Roxana GarlandTIME COMPLETED:
01:25 PM
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On October 27, 2022 at 10:25 a.m. Licensing Program Analyst, Leilani Curtis, conducted an unannounced inspection to follow up on a self-reported incident that occurred on 10/6/22, wherein a child (C1) lost his balance climbing up the steps of the playground play structure, fell, and hit his head on the play structure before falling to the ground. LPA met with Assistant Director Roxana Garland and proceeded to tour the facility. There were 55 children with 18 staff members present. Appropriate ratio/capacity was observed. Staff members have the required background clearances and are associated to the facility.

LPA interviewed the assistant director, staff #1 (S1) via telephone while at the facility, staff #2 (S2), and staff #3 (S3). On 10/6/22 at approximately 9:30 a.m. C1 was climbing up the steps of the play structure when he lost his balance, bumped his head on the play structure and then fell to the ground. C1 sustained a cut on the back of his head. Facility staff applied ice and a clean towel with pressure to the wound. C1 was taken to the office where the director cleaned the cut on his head and his mother was called. The parent was given an incident report at the time of pick up. The parent of C1 took the child to the doctor where he received stitches or staples to the injured area. Asst. Director Garland states that at the time of the incident there were 12 children on the playground being supervised by 5 staff members. Appropriate ratio/supervision was in place. The staff members responded to the injury appropriately and reported timely. LPA inspected the playground where the incident occurred. LPA observed the play structure to be free from hazards and the area around and under the play structure/climbing equipment is cushioned with rubber material that absorbs falls. Signage next to the play structure states that it is designed for users 18 months to 5 years old. The distance from the top step where the child fell from is approximately 2 feet, 10 inches from the ground. Assistant Director states that on 10/21/22 a staff meeting was held to discuss active supervision and staff location on the playground.

No deficiency cited.
An exit interview was conducted with Assistant Director Garland and Appeal Rights (LIC 9058) were discussed. Ms. Garland'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 Ms. Garland post notice of site visit.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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