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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701228
Report Date: 10/03/2022
Date Signed: 10/03/2022 11:58:21 AM

Document Has Been Signed on 10/03/2022 11:58 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CHILDREN'S CHOICE ACADEMYFACILITY NUMBER:
376701228
ADMINISTRATOR:SHANNON SPENCERFACILITY TYPE:
850
ADDRESS:12464 WOODSIDE AVENUETELEPHONE:
(619) 561-8880
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: DATE:
10/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Shannon TIME COMPLETED:
12:00 PM
NARRATIVE
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On 10/3/22 LPA Annette Sutherland was at the facility for an inspection concerning another matter. LPA toured facility and took a census. LPA was unable to locate staff #1 on association list. Licensee was unable to provide proof of association .

Type B deficiencies cited on LIC 809D

An exit interview was conducted with the Director. Notice of Site Visit (LIC 9213, Appeal Rights (LIC 9058) and a copy of the report (LIC809) was provided to Director .The Notice of Site Visit was posted during todays visits. Notice of site Visit must remain posted for 30 days.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/03/2022 11:58 AM - It Cannot Be Edited


Created By: Annette Sutherland On 10/03/2022 at 10:59 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: CHILDREN'S CHOICE ACADEMY
FACILITY NUMBER: 376701228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2022
Section Cited
CCR
101216(i)(2)

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101216 (i)(2) Personnel Requirements: Request a transfer of a criminal record clearance as specified in Section 101170(f). This requirement was not met as evidence by:
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Director will associate staff to preschool program and submit proof by POC date of 10/3/22. Proof will be maintained in staff file.
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Based on observation and record review. Staff #1 is clear but not associated to the preschool program. This posses an potential risk to the health ans safety of the children in care.
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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:Annette Sutherland
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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