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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700946
Report Date: 12/02/2021
Date Signed: 12/02/2021 12:48:49 PM

Document Has Been Signed on 12/02/2021 12:48 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:CAPSLO BOYS & GIRLS CLUB HEAD STARTFACILITY NUMBER:
376700946
ADMINISTRATOR:ALICIA JONESFACILITY TYPE:
850
ADDRESS:12988 BOWRON ROADTELEPHONE:
(858) 668-2985
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 31DATE:
12/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Director Renee McBride and Cheryl Marshall, Education CoordinatorTIME COMPLETED:
12:50 PM
NARRATIVE
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On 12/2/2021 @11:10 a.m., Licensing Program Analysts, Joelle Redding and Patrick Ma, made an unannounced visit to evaluate the circumstances surrounding a self-reported incident that occurred on 11/5/21 wherein a 4 year old child (Child #1) was left behind on the playground during transition.

During today's visit, LPAs spoke with Staff #1-3 and the Director. The Director and lead teacher who were present at the time of the incident are no longer with the organization and were not available for interview.. According to the information obtained, 17 children were on the playground. The lead teacher and Staff #1 were supervising the children on the playground when Staff #1 was called away and Staff #2 substituted for her to assist the lead teacher with the transition back into the classroom. It is school policy to count the children as they line up to transition inside. It is not clear whether the lead teacher recounted as the children entered. Child #1 was subsequently noted to be missing from the group approximately 1-2 minutes later by Staff #3. The lead teacher opened the classroom door to find Child #1 drawing at a table close to the door.

A Type B deficiency will be cited on the accompanying LIC 809D as a potential hazard to children in care.

Notice of Site Visit was given and will be posted for 30 days.
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Joelle Redding
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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 12/02/2021 12:48 PM - It Cannot Be Edited


Created By: Joelle Redding On 12/02/2021 at 12:12 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: CAPSLO BOYS & GIRLS CLUB HEAD START
FACILITY NUMBER: 376700946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2021
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs...No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation. This requirement was not met as evidenced by:
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Director states that since the incident, the furnishings on the playground have been rearranged to allow for improved visual supervision, transitions have improved to include counting children in smaller groups as they proceed into the classroom and an Active Supervision policy has been provided to all Directors. Director states that staff has been
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Based on interview and record review, Child #1 was left behind on the playground during a transition into the classroom, for approximately 1-2 minutes. This is a potential, rather than immediate hazard to the health and safety of children in care as Child #1 was without supervision, in a contained area, for no more than 2 minutes.
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trained on the new policy. She provided a copy of the Plan and roster today. No further correction is required at this time.

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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 Pack
LICENSING EVALUATOR NAME:Joelle Redding
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021


LIC809 (FAS) - (06/04)
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