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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600650
Report Date: 08/12/2021
Date Signed: 08/12/2021 12:30:43 PM

Document Has Been Signed on 08/12/2021 12:30 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:KINDERCARE - CARLSBADFACILITY NUMBER:
376600650
ADMINISTRATOR:REBEKAH SITOMPULFACILITY TYPE:
850
ADDRESS:1200 PLUM TREE ROADTELEPHONE:
(760) 435-0001
CITY:CARLSBADSTATE: CAZIP CODE:
92011
CAPACITY: 125TOTAL ENROLLED CHILDREN: 0CENSUS: 53DATE:
08/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Beatriz CornejoTIME COMPLETED:
12:45 PM
NARRATIVE
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On 8/12/21, Licensing Program Analyst's Michael Morales-DeSilvestore and Joelle Redding made an unannounced visit to follow up on a self reported incident that occurred on 6/28/21 wherein a 2 year old child (Child #1) was left behind on the playground when the door closed during a transition from the playground to the classroom.

LPA's spoke with Staff #1 who stated that they had all the children accounted for against the gate just outside the door to the classroom. Staff #1 started calling names and checking off children on the Child Supervision Record (CSR). As the children entered the classroom, Staff #2 went inside the classroom with the first group of kids to help wash their hands and get them ready for reading a book. Staff #1 recalled seeing child#1 lined up at the fence and checked his name off the CSR but cannot recall him directly going into the classroom. The child wandered off at this time back onto the playground unnoticed. Once the rest of the class was inside with Staff#1 and #2 they closed the door and started getting everyone ready for reading a book. Before the teachers started reading the book, Director Rebekah S. came into the classroom to inform the teachers that child #1 was found outside on the playground by another staff member. Child #1 was left outside alone with the classroom door shut for no more than 5 minutes.

A Type B deficiency will be cited on the accompanying LIC 809D. Appeal Rights (1/16) were discussed and provided. Signature at the bottom of this report confirms receipt.

NOTICE OF SITE VISIT WAS POSTED AND WILL REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Michael Morales-DeSilvestore
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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 2
Document Has Been Signed on 08/12/2021 12:30 PM - It Cannot Be Edited


Created By: Michael Morales-DeSilvestore On 08/12/2021 at 11:57 AM
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: KINDERCARE - CARLSBAD
FACILITY NUMBER: 376600650

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2021
Section Cited
CCR
101229(a)(1)

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(a)(1) Responsibility for Providing 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 not met as evidenced by:
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Assistant Director stated they conducted a staff training on transitions including roll playing transitions with Staff #1 & 2. Facility will submit training sign in sheet to the Department by 8/20/21.
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Based on interview and record review, the facility did not ensure that visual observation was maintained at all times based on child #1 being left alone on the playground for no more than 5 minutes which poses a potential health and safety 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.
SUPERVISOR'S NAME:Tashima Daniel
LICENSING EVALUATOR NAME:Michael Morales-DeSilvestore
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021


LIC809 (FAS) - (06/04)
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