Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364808719
Report Date: 11/10/2015
Date Signed 11/10/2015 02:16:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:AVUSD MARIANA STATE PRESCHOOLFACILITY NUMBER:
364808719
ADMINISTRATOR:BILL CLAYFACILITY TYPE:
850
ADDRESS:10601 MANHASSET ROADTELEPHONE:
(760) 247-7258
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:48CENSUS: 20DATE:
11/10/2015
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Debora CornellTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joanne Domingo arrived at the facility on a case management visit to follow-up on an unusual incident report submitted by the facility on 10/26/15 that a child was left on the outside ramp to the classroom. At the time of visit, LPA Domingo toured the facility, took census, and met with Associate Teacher, Debora Cornell to discuss the reported incident. Ms. Cornell and Substitute Teacher, Ms. Ly (who was not present during this visit) were the staff present during the incident.
Based on the information obtained during the visit, as well as an inspection of the area where the child was left, there appeared to be a violation of Title 22 Regulations pertaining to the reported incident.
A child was left outside on the ramp to the classroom after returning with a substitute teacher and 5 classmates from a bathroom break. The substitute teacher failed to count the children returning from the bathroom and as a result the classroom door was closed and the child was left on the ramp. Several school aged children had noticed the child crying on the ramp and notified the teacher inside the classroom.

This is a Type A violation - see LIC. 809 D for deficiency and a zero tolerance. Title 5 program not subject civil penalty.

Absence of Supervision, including, but not limited to, a child left unattended, a child left alone with a person under 18 years of age, and lack of supervision resulting in a child wandering away. (HSC Section 1596.99(c)(2))

Notice of Site Visit must be posted in an area accessible to parents for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC.9099/LIC.809D) must be posted for 30 days. LPA explained that a type A deficiency if cited, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

A copy of this report must be made available to the public for 3 years.
SUPERVISOR'S NAME: Marianne DonleyTELEPHONE: (951)782-4200
LICENSING EVALUATOR NAME: Joanne DomingoTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2015
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: AVUSD MARIANA STATE PRESCHOOL
FACILITY NUMBER: 364808719
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2015
Section Cited
101229(a)(1)
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Lack of Supervision: No children shall be left without the supervision including visual observation of a teacher at any time. A child was left in the classroom for approximately 5 - 10 minutes unattended.
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A training was provided to all staff members and substitute teachers. A counting system has been established as a check and balance between staff members for all classroom transitions and bathroom breaks.
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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: Marianne DonleyTELEPHONE: (951)782-4200
LICENSING EVALUATOR NAME: Joanne DomingoTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2015
LIC809 (FAS) - (06/04)
Page: 2 of 2