CAPC - STELLA BROCKMAN

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analysts (LPAs) Lauren Scott and Tobias Lake met with Site Supervisor, Makayla Hannah, and Lead Teacher, Nesia Osorio, to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 11/8/2022. The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incident. During today's visit the facility was toured. Present were 14 school age children in care and 3 staff. LPAs interviewed the Site Supervisor and Lead Teacher who were present during the incident. LPAs reviewed and discussed this report with the Site Supervisor and Lead Teacher. Lead Teacher stated two children were on top of the play structure and ran into each other, causing one child's tooth to dislodge. The child was taken to the doctor and dentist. The child was instructed to stay home for 14 days by the doctor due to the inability to eat solid foods. LPA requested a copy of the doctor report, Site Supervisor stated she would ask the parents for it. LPAs conducted an observation of the play structure and outside area. Upon inspection, LPA saw the sign on the play structure that stated ages 5-12. LPA reviewed the facility's files and their prelicensing visit that was conducted in June 2020. The prelicensing inspection report states the children are not allowed to use this play structure. Although the facility has a shared outdoor space waiver, it states all staff will ensure that children are using age appropriate equipment at all times. Facility evaluation report was reviewed and discussed with Site Supervisor and Lead Teacher. Exit interview was conducted. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. SUPERVISORS NAME: Chayntel Hunter LICENSING EVALUATOR NAME: Lauren Scott LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022 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 3 FACILITY NAME: CAPC - STELLA BROCKMAN FACILITY NUMBER: 394500231 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 11/22/2022 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type A 11/22/2022 Section Cited CCR 101223(a)(2) 1 2 3 4 5 6 7personal rights (a)The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by1 2 3 4 5 6 7Facility is making the play structure off limits immediately. Staff will be using signs in the entrances of the play structure, preventing children from entering. Staff will be supervising the area and preventing children from entering as well. 8 9 10 11 12 13 14Children were allowed to use the play structure that was not licensed for the facility, stating it is only for the school age children (ages 5-12) with whom they share a outdoor space with. This is an immediate health and safety risk to children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Chayntel Hunter LICENSING EVALUATOR NAME:Lauren Scott LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022 FACILITY NAME: CAPC - STELLA BROCKMANFACILITY NUMBER: 394500231 VISIT DATE: 11/22/2022 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32LPA Scott informed Site Supervisor, Mikayla Hannah, and Lead Teacher, Nesia Osorio, that this report dated November 22, 2022 documents one Type A citations which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care. Also, LPA Scott informed the Site Supervisor and Lead Teacher to provide a copy of this licensing report dated November 22, 2022 that documents any Type A citations to parents/ guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in

Type A citation - immediate risk to health, safety, or personal rights

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analysts (LPAs) Lauren Scott and Tobias Lake met with Site Supervisor, Makayla Hannah, and Lead Teacher, Nesia Osorio, to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 11/8/2022. The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incident. During today's visit the facility was toured. Present were 14 school age children in care and 3 staff. LPAs interviewed the Site Supervisor and Lead Teacher who were present during the incident. LPAs reviewed and discussed this report with the Site Supervisor and Lead Teacher. Lead Teacher stated two children were on top of the play structure and ran into each other, causing one child's tooth to dislodge. The child was taken to the doctor and dentist. The child was instructed to stay home for 14 days by the doctor due to the inability to eat solid foods. LPA requested a copy of the doctor report, Site Supervisor stated she would ask the parents for it. LPAs conducted an observation of the play structure and outside area. Upon inspection, LPA saw the sign on the play structure that stated ages 5-12. LPA reviewed the facility's files and their prelicensing visit that was conducted in June 2020. The prelicensing inspection report states the children are not allowed to use this play structure. Although the facility has a shared outdoor space waiver, it states all staff will ensure that children are using age appropriate equipment at all times. Facility evaluation report was reviewed and discussed with Site Supervisor and Lead Teacher. Exit interview was conducted. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. SUPERVISORS NAME: Chayntel Hunter LICENSING EVALUATOR NAME: Lauren Scott LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022 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 3 FACILITY NAME: CAPC - STELLA BROCKMAN FACILITY NUMBER: 394500231 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 11/22/2022 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type A 11/22/2022 Section Cited CCR 101223(a)(2) 1 2 3 4 5 6 7personal rights (a)The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by1 2 3 4 5 6 7Facility is making the play structure off limits immediately. Staff will be using signs in the entrances of the play structure, preventing children from entering. Staff will be supervising the area and preventing children from entering as well. 8 9 10 11 12 13 14Children were allowed to use the play structure that was not licensed for the facility, stating it is only for the school age children (ages 5-12) with whom they share a outdoor space with. This is an immediate health and safety risk to children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Chayntel Hunter LICENSING EVALUATOR NAME:Lauren Scott LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022 FACILITY NAME: CAPC - STELLA BROCKMANFACILITY NUMBER: 394500231 VISIT DATE: 11/22/2022 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32LPA Scott informed Site Supervisor, Mikayla Hannah, and Lead Teacher, Nesia Osorio, that this report dated November 22, 2022 documents one Type A citations which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care. Also, LPA Scott informed the Site Supervisor and Lead Teacher to provide a copy of this licensing report dated November 22, 2022 that documents any Type A citations to parents/ guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in