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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700775
Report Date: 11/07/2022
Date Signed: 11/07/2022 02:41:55 PM

Document Has Been Signed on 11/07/2022 02:41 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 PROJECT HEAD START CARLSBAD 1 - EUREKA PLACEFACILITY NUMBER:
376700775
ADMINISTRATOR:JACQUELYN BISKUPSKIFACILITY TYPE:
850
ADDRESS:3368 EUREKA PLACETELEPHONE:
(760) 720-4378
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 82TOTAL ENROLLED CHILDREN: 44CENSUS: 34DATE:
11/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Jacquelyn BiskupskiTIME COMPLETED:
02:50 PM
NARRATIVE
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On 11/07/2022 at 12:31PM, Licensing Program Analyst (LPA) Samantha Clenista conducted an unannounced case management site inspection to follow up on a self-reported incident that occurred on 10/20/2022. Upon arrival LPA met with Center Director, Jacquelyn Biskupski, and proceeded to tour the facility. During today's inspection, there were 34 children with 7 staff members in 3 classrooms. Appropriate ratios and capacity were observed. Appropriate care & visual supervision were also observed during the inspection. Children were observed either eating lunch or playing outside.

The incident that occurred on 10/20/2022 involved how Staff #1 removed Child #1's plate while the child was still eating and was asked to go lay down on their cot, which caused emotional distress to Child #1. It is to be noted that Child #1 verbally stated they were not finished eating, yet Staff #1 still removed the plate and threw out the meal. The facility self-reported this incident as there were multiple witnesses.

Based upon information gathered and supporting documents, it has been confirmed that Child #1's personal rights were violated during this incident.

See 809D for cited deficiency. Exit interview was conducted with Director. LPA provided a copy of LIC 9213, “Notice of Site Visit,” and observed Director post it at conclusion of visit. LIC9213 shall remain posted for 30 consecutive days.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Samantha Clenista
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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 11/07/2022 02:41 PM - It Cannot Be Edited


Created By: Samantha Clenista On 11/07/2022 at 11:59 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: MAAC PROJECT HEAD START CARLSBAD 1 - EUREKA PLACE
FACILITY NUMBER: 376700775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2022
Section Cited
CCR
101223(a)(3)

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Personal Rights. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating..." This requirement was not met as evidenced by;
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Facility immediately took action and placed Staff #1 on a discipline plan after hearing about the incident and Staff #1 soon after went on leave (return date is TBD). LPA provided Director with the Personal Rights regulation (section 101223) to review with her current staff.
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Child #1 personal rights were violated as Staff #1 took Child #1's plate and threw out the meal while Child #1 was still eating and verbally stated they were still eating. Child #1 was left emotionally distressed as they were asked to lay on their cot after not being able to finish their food. This poses a Potential Health and Safety risk to the clients in care.
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Director stated that she will host a staff meeting to review the regulation and have them acknowledge that they reviewed/understood it. Director stated that she will provide LPA a staff sign in sheet for all staff that attend the meeting, no later than 11/30/2022.

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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:Monica Cuddy
LICENSING EVALUATOR NAME:Samantha Clenista
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022


LIC809 (FAS) - (06/04)
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