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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701522
Report Date: 05/02/2024
Date Signed: 05/02/2024 12:50:32 PM

Document Has Been Signed on 05/02/2024 12:50 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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:COZY CUBS 3 - INFANTSFACILITY NUMBER:
376701522
ADMINISTRATOR/
DIRECTOR:		ANNETTE KURTENBACHFACILITY TYPE:
830
ADDRESS:8475 LA MESA BLVDTELEPHONE:
(619) 460-0393
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: 16TOTAL ENROLLED CHILDREN: 16CENSUS: 12DATE:
05/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Maria Morales and Annette KurtenbachTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
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On 5/2/2024, at 9:35 am.,Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management inspection. The purpose of the inspection is cite for deficiencies observed during another inspection at the facility. LPA met with Assistant Director, Maria Morales. LPA discussed the purpose of the inspection and proceeded to tour the facility. There were four (4) children present in infant classroom B with one (1) teacher and one (1) aide. LPA observed seven (7) children on the playground with one (1) teacher and one aide. At 10:00am, Facility Representative, Annette Kurtenbach arrived to the facility.

During the inspection, LPA Williamson observed in classroom B, Child #1 (C1) asleep in a crib with a blanket covering his body. LPA reviewed C1's records during the inspection.

During the inspection, LPA obtained pertinent documentation, reviewed and discussed PIN 20-24-CCP Safe Sleep Regulation.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited. See LIC809 D.

Exit interview was conducted with Facility Representative, Annette Kurtenbach and Assistant Director, Maria Morales and a copy of this report, Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit is required to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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Document Has Been Signed on 05/02/2024 12:50 PM - It Cannot Be Edited


Created By: Vicky Williamson On 05/02/2024 at 11:16 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: COZY CUBS 3 - INFANTS
FACILITY NUMBER: 376701522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2024
Section Cited
CCR
101439.1(f)

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101439.1 Infant Care Center Sleeping Equipment (f) Cribs shall be free from all loose articles and objects, including blankets and pillows.

This requirement was not met as evidence by:
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Deficiency cleared during time of inspection. Staff 1 removed the blanket from the crib immediately. LPA reviewed and discussed PIN 20-24-CCP with Facility Representative and Assistant Director.
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Based on observation and interview, the licensee did not comply with the section cited above as LPA Williamson observed Child #1 asleep in a crib with a blanket covering his which poses a potential health, safety or personal rights risk to persons 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:Tulam Vu
LICENSING EVALUATOR NAME:Vicky Williamson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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