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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700946
Report Date: 09/15/2025
Date Signed: 09/15/2025 11:51:46 AM

Document Has Been Signed on 09/15/2025 11:51 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CAPSLO BOYS & GIRLS CLUB HEAD STARTFACILITY NUMBER:
376700946
ADMINISTRATOR/
DIRECTOR:		RENEE MCBRIDEFACILITY TYPE:
850
ADDRESS:12988 BOWRON ROADTELEPHONE:
(858) 668-2985
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 27DATE:
09/15/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Tania BelloTIME VISIT/
INSPECTION COMPLETED:
12:02 PM
NARRATIVE
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On 9/15/25 at 9:15 a.m., Licensing Program Analyst, Renita Rodriguez, made an unannounced visit to evaluate the circumstances surrounding a self-reported incident that occurred on 8/19/25 wherein C1 entered classroom 1 from the outdoor play area unsupervised.

Ratios observed today were 27 children with 5 staff.

During today's visit, LPA conducted interviews, according to the information obtained, the ratio for classroom 1 during time of the incident was 11 children and 3 staff. Classroom 1 was engaging in outdoor activities. S1 left the outdoor play area to use the restroom. S2 was sitting in the office area during their break time from around 9:15 a.m - 9:30 a.m. S2 heard a door sound. S2 states it was the door in classroom 1 which leads to the outdoor play area. The office and classroom 1 are next to each other with half walls. S2 then heard footsteps of a child in classroom 1. S2 entered classroom 1 and found C1 alone in the classroom. S2 returned the child to the outside play area to S3. S3 and S4 were outside with children when C1 entered classroom 1 unsupervised. Child was alone for less than a minute.

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

Notice of Site Visit was given and will be posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Renesha Askew
NAME OF LICENSING PROGRAM ANALYST: Renita Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/15/2025 11:51 AM - It Cannot Be Edited


Created By: Renita Rodriguez On 09/15/2025 at 10:08 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: CAPSLO BOYS & GIRLS CLUB HEAD START
FACILITY NUMBER: 376700946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2025
Section Cited
CCR
101229(1)

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101229 Responsibility for Providing 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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C1 was returned immediately with their classroom. Director states staff involved have been given corrective actions. Staff members involved have been given training to remind and go over Active Supervision.
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Based on observation and interviews the facility did not ensure the supervision of C1 during outdoor activities, which posed a potential Health, Safety or Personal Rights risks to persons in care.
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Prior to incident Active supervision training was completed on 8/14/25. Director will meet with all the staff regarding active supervision on 9/18/25. Staff meetings will continue to be completed once a month and active supervision will be discussed.

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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.
Renesha Askew
NAME OF LICENSING PROGRAM MANAGER:
Renita Rodriguez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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