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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100043
Report Date: 06/27/2023
Date Signed: 06/27/2023 12:41:34 PM

Document Has Been Signed on 06/27/2023 12:41 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:MARTINS, JASON FAMILY CHILD CAREFACILITY NUMBER:
376100043
ADMINISTRATOR:JASON MARTINSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 705-4160
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
06/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Jason MartinsTIME COMPLETED:
12:45 PM
NARRATIVE
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On 06/27/2023 at 11:35am, Licensing Program Analyst (LPA) Selina Siao conducted an unannounced case management visit. On 05/05/2023, a day care infant fell down on the carpeted floor while pulling his blanket that was hanged on the wall. The day care parent had informed the licensee that the child will be taken to the doctor on Monday 05/08/2023 as the child's shoulder was in pain. Licensee stated that he didn't think that the child's fall would required medical treatment as the child appears to be fine after the fall.

Licensee had spoke with a Detective who went to the facility to find out how the child's injury occurred. Licensee failed to report this unusual incident to the licensing department after he talked to the detective as required per regulation.

LPA Siao provided a copy of the regulation 102416.2 Reporting Requirement and H&S 1597.467 to licensee during today's inspection.

See LIC809D for citation issue.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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 08/10/2023 02:21 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/10/2023 01:43 PM


Created By: Selina Siao On 06/27/2023 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: MARTINS, JASON FAMILY CHILD CARE
FACILITY NUMBER: 376100043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2023
Section Cited
CCR
102416.2(b)(3)(B)

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Reporting Requirements
A report shall be made to the Department…following the occurrence ....of the following events: Any injury to any child that requires medical treatment.
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Licensee submitted the unusual incident report LIC624 to the licensing department on 05/17/2023.
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This requirement is not met as licensee was aware that a day care infant was taken to the doctor on 05/08/2023 due to a fall incident that happened at the facility on 05/05/23. Licensee should have report the incident to the licensing department when he found out the child went to the doctor after talking to the detective on 05/10/2023. This poses a potential health and safety risk to clients 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:Tashima Daniel
LICENSING EVALUATOR NAME:Selina Siao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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