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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700099
Report Date: 12/07/2022
Date Signed: 12/07/2022 04:24:36 PM

Document Has Been Signed on 12/07/2022 04:24 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:BIRD ROCK ELEMENTARYFACILITY NUMBER:
376700099
ADMINISTRATOR:JILL FISHFACILITY TYPE:
840
ADDRESS:5371 LA JOLLA HERMOSA AVENUETELEPHONE:
(619) 605-3500
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 38DATE:
12/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Child Care Coordinator Jenny GutierrezTIME COMPLETED:
03:00 PM
NARRATIVE
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On 12/7/2022 @ 2:30 p.m., Licensing Program Analyst (LPA), Joelle Redding, made an unannounced visit to follow up on a self-reported incident that occurred on 11/18/2022.

During this visit, LPA spoke with Ms. Gutierrez who is currently supervising and was present on the day of the event. Based on the information provided, lack of direct supervision by Staff #1 resulted in children engaging in an inappropriate game. Staff #1 member is longer employed with the YMCA.

A Type B deficiency will be issued on the accompanying LIC 809D

NOTICE OF SITE VISIT WAS GIVEN AND WILL REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Joelle Redding
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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Document Has Been Signed on 12/07/2022 04:24 PM - It Cannot Be Edited


Created By: Joelle Redding On 12/07/2022 at 04:00 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: BIRD ROCK ELEMENTARY
FACILITY NUMBER: 376700099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2022
Section Cited
CCR
101229(a)(1)

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Responsibiity for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs...Supervision shall include visual observation.

This requirement was not met as evidenced by:
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Ms. Gutierrez states that immediately upon becoming aware of the incident that day, she addressed the children directly and as a group, contacted parents and on 11/28, a staff wide meeting on Active Supervision was conducted. An agenda and roster will be provided to Licensing via email. An internal review was conducted and it was determined that Staff #1
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Based on interview Ms. Gutierrez who was present in a different room at the time of the event, Staff #1 did not provide sufficient supervision over a group of 8 children, resulting in some of the children engaging in an appropriate game. This is a potential hazard to the health and safety of children in care.
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did not provide appropriate supervision to prevent the situation and is no longer employed with the YMCA.


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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:Renesha Askew
LICENSING EVALUATOR NAME:Joelle Redding
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022


LIC809 (FAS) - (06/04)
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