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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700416
Report Date: 07/25/2022
Date Signed: 07/25/2022 02:40:24 PM

Document Has Been Signed on 07/25/2022 02:40 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:SKYLINE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
376700416
ADMINISTRATOR:JACQUELINE SERRANOFACILITY TYPE:
850
ADDRESS:11330 CAMPO ROADTELEPHONE:
(619) 415-5485
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 43DATE:
07/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jacqueline Serrano, Facility DirectorTIME COMPLETED:
02:40 PM
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On July 25, at 2:00 PM, Licensing Program Analyst (LPA), Marie Hernandez conducted an unannounced Case Management Inspection due to an incident with child #1. On 05/25/2022, the Department received the incident report from the facility for child #1. LPA met with the facility director, Jacqueline Serrano. Through the course of the incident review, LPA interviewed the staff. The child could not be interviewed.

The facility reported that on 05/25/2022 at approximately 12:00 PM, during transition from lunch to nap time, child #1 was on her cot, stood up, lost her balance and tripped on her napping blanket, hitting the corner of the toy shelf. The child sustained an injury to the upper gum line area. The parent was contacted and took child to the doctors. However, the injury did not require any stitches. The staff observed the incident with child #1. LPA inspected the classroom and napping area for safety hazards and did not observe any at time of visit. The staff was proactive by tending to child’s needs. The incident was an accident. This concludes the incident review.

An exit interview was conducted and the report was provided to the facility director, Jacqueline. The Notice of Site Visit was provided and posted by the Facility Director.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Marie Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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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