Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700007
Report Date: 09/07/2017
Date Signed 09/08/2017 06:32:11 PM

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:KIDS ON BROADWAYFACILITY NUMBER:
376700007
ADMINISTRATOR:CHRISTINA MARTINEZFACILITY TYPE:
830
ADDRESS:475 W. BROADWAYTELEPHONE:
(619) 557-3431
CITY:SAN DIEGOSTATE: CAZIP CODE:
92101
CAPACITY:24CENSUS: 20DATE:
09/07/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Christina MartinezTIME COMPLETED:
01:30 PM
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Licensing Program Analyst, Rita Magaña was on site for the purpose of conducting an investigation into a self reported unusual incident. Today, four staff were interviewed. Staff will provide some additional details about their written narratives.

The investigation is continuing.






This is an electronic copy of a handwritten report. Please see facility file for original signatures. The following information regarding ADA was provided: US Department Of Justice (USDOJ) toll-free ADA Information (800) 514-0301 (voice) (800) 514-0383(TTY) and link to publication: Commonly Asked Questions about Child Care Facilities and the ADA, available at: http://www.ada.gov/childqanda.htm Community Care Licensing: WEB SITE: http://www.ccld.ca.gov The report shall remain available at the facility for public review for three years. LIC 9213 was visibly posted today, for 30 days. The licensee was provided a copy of their appeal rights (LIC 9058, 12/15) and their signature on this form acknowledges receipt of these rights. Appeal must be received within 15 days.
SUPERVISOR'S NAME: Carl SheltonTELEPHONE: (619) 767-2205
LICENSING EVALUATOR NAME: Rita MaganaTELEPHONE: (616) 767-2213
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2017
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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