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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700416
Report Date: 01/25/2024
Date Signed: 01/25/2024 10:56:29 AM

Document Has Been Signed on 01/25/2024 10:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 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: 74CENSUS: 55DATE:
01/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Jacqueline SerranoTIME COMPLETED:
11:10 AM
NARRATIVE
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On 1/25/2024, at 9:35 am., Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management inspection to follow up on a self reported incident. LPA met with Director, Jacqueline Serrano. LPA discussed the purpose of the inspection and was led on a tour of the facility. There were 55 children present with 9 staff members.

Director reported that on 1/9/2024 at 9:18am there were two (2) staff and 17 children on the upper preschool playground. Director stated that at 9:29am, Staff 1 (S1), Staff 2 (S2) and 16 children began transitioning from the playground to the inside of the building. Director stated that Child (C1) was inside of a play structure and left alone on the fully fenced locked playground for approximately 14 minutes without supervision. Director stated that the facility was notified by a church employee that C1 was observed alone on the playground. Upon notification, Staff 3 (S3) immediately went to the playground and retrieved C1. Per S3, there were no injuries observed on C1.

Interviews were conducted with the director, assistant director, staff and daycare parent. C1 was not available for interview. A review of video footage disclosed that C1 was on the playground with one teacher, one assistant and 16 children. The video footage showed S1 and S2 lining the children up to transition from the playground. At 9:24am the staff and children left the playground. C1 was observed underneath a play structure. Interviews with staff disclosed that the name to face procedures, inspection of the playground and play structures was not conducted prior to transitioning from playground. At 9:40am, S3 was observed entering the gate of the upper playground and retrieving C1 from the playground. C1 was left on the fully fenced locked playground for 16 minutes.

Director stated that a training regarding supervision of children will be conducted. Director stated that she has implemented signs near the entrance and exit door to remind staff to conduct the name to face.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: SKYLINE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 376700416
VISIT DATE: 01/25/2024
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Based on interviews and video footage, one (1) Type A deficiency of California Code of Regulations, Title 22, Division 12, Chapter 1, is being cited on the attached LIC 809D.

LPA informed Director, Jacqueline Serrano that this report dated 1/25/2024 documents one (1) Type A citation, which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed Director, Jacqueline Serrano to provide a copy of this licensing report dated 1/25/2024 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. LPA provided Director, Jacqueline Serrano with form LIC 9224.

A copy of this report along with the Appeals Rights (LIC 9058) were provided. A Notice of Site Visit was provided and is required to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. LPA observed Director post Notice of Site Visit on the bulletin board. An exit interview conducted with Director, Jacqueline Serrano.

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2024 01:56 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/22/2024 06:44 AM


Created By: Vicky Williamson On 01/24/2024 at 08:26 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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: SKYLINE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 376700416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2024
Section Cited
CCR
101229(a)(1)

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101229(a) The licensee shall provide care and supervision... (1) 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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Director stated that she will retrained staff on supervision, policy and procedures. Director stated that the training will include role playing and scenarios. Director will submit the agenda, summary of training and sign in sheet to the SDRO, no later than 2/2/2024
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Based on interview and record review, the licensee did not comply with the section cited above as Child 1 (C1) was left on the playground alone without supervision for 16 minutes, which poses an immediate health, safety, and personal rights risk to persons in care.
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This is an amended version of the original report dated 1/25/2024.

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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:Tulam Vu
LICENSING EVALUATOR NAME:Vicky Williamson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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