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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150407178
Report Date: 04/04/2022
Date Signed: 04/04/2022 11:56:22 AM


Document Has Been Signed on 04/04/2022 11:56 AM - 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, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:HORACE MANN ELEMENTARY SCHOOLFACILITY NUMBER:
150407178
ADMINISTRATOR:RUSSELL GAYERFACILITY TYPE:
850
ADDRESS:2710 NILES STREETTELEPHONE:
(661) 631-4936
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:24CENSUS: 15DATE:
04/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Program Coodinator, Storiann CampsTIME COMPLETED:
12:30 PM
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On this date, (04/04/22) Licensing Program Analysts (LPAs) Gloria Reyes and Cynthia Brannon met with Teachers Marta Martinez and Debra Scott, Program Coordinator, Storiann Camps and Principal, Russell Gayer for an unannounced Case Management - Incident inspection. LPAs toured the facility and a census was taken. There are 15 children present. An Unusual Incident Report was submitted to the Fresno Community Care Licensing Office regarding an incident that occurred on 03/18/22, at approximately 10:43 AM, on the school play yard where Child #1, sustained an inch and a half wound that required stiches. Child #1 was running on the grass area when the child tripped hitting his/her face on the cement between the play structure and the grass area. The child’s parents were contacted, picked up their child and child was taken to the Emergency Room at Kern Medical Center. The child received stiches near the forehead, was released and returned to the center without restrictions on 03/21/22.

The Program Coordinator (Storiann Camps) and Principal (Russell Gayer) met with District Maintenance Supervisor and inspected the outside play yard where the incident occurred and found no obstructions. Staff will continue to remind children about inside and outside safety rules.

LPA Reyes interviewed both teachers. Staff #1 reported the child received stiches above his/her nose between his/her eyebrows about an inch and a half long. The child is doing fine. There were 14 children and one staff on the play yard when the incident took place. Staff #2 reported that she took another child to use the restroom and did not observe the incident. LPA discussed with Ms. Camps and Mr. Gayer observations made today by LPAs. LPAs recommended that a barrier be placed between the play structure and the grass area to prevent any future accidents. Also, additional wood chips will be added to the wood chips area and walkie talkies will be provided to the teachers for better communication between the office and the preschool. Incident Medical Services will also be updated to address possible changes to the administer of Inhaled Medication. If changes are made, then an updated IMS Plan must be submitted to licensing for review. Within 30 days, Licensee to notify licensing of any changes made. (see next page)
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Gloria ReyesTELEPHONE: (559) 341-4471
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: HORACE MANN ELEMENTARY SCHOOL
FACILITY NUMBER: 150407178
VISIT DATE: 04/04/2022
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Per California Code of Regulations, Title 22, Division 12, Chapter 1, no deficiency was cited.

An exit interview conducted with Program Coordinator, Storiann Camps. A copy of this report was provided and discussed. A Notice of Site Visit Form is posted to parent's board and must remain posted for 30 days.
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Gloria ReyesTELEPHONE: (559) 341-4471
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
LIC809 (FAS) - (06/04)
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