163808356-10-8-2019-04-CC-KPAO-BGRNFZ-20191008102622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 163808356
Report Date: 10/07/2019
Date Signed: 10/08/2019 10:26:26 AM

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:	HIS KIDS PRESCHOOL		FACILITY NUMBER:	163808356
ADMINISTRATOR:	MEYER, SONJA		FACILITY TYPE:	850
ADDRESS:	750 E. GRANGEVILLE BLVD.		TELEPHONE:	(559) 584-8558
CITY:	HANFORD	STATE: CA	ZIP CODE:	93230
CAPACITY:	47	CENSUS: 34	DATE:	10/07/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Sonja Meyer		TIME COMPLETED:	10:00 AM

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	On this date, Licensing Program Analyst (LPA) Kathy Pacheco conducted an unannounced case management inspection at the facility. LPA met with Administrator, Sonja Meyer, to discuss an incident that occurred on 9/25/19. A complete file review was conducted prior to the inspection. LPA toured facility, took a census, interviewed staff and children, and observed the area in which the incident occurred. On 9/25/19, child #1 (see Confidential Names Form (LIC 809) dated 10/7/19) and child #2 (see LIC 809) were in classroom #1 with Teacher Bailey Pannett present. Teacher stated the children were in the process of cleaning up and transitioning to the circle time rug. She said when children have finished cleaning up, they go and sit down on the circle time rug. Teacher said child #1 usually sits on one corner of the rug and child #2 sits on the opposite side of the rug. She said on that day, she noticed child #1 had gone to sit where child #2 usually sits. Teacher said around the time she noticed that, there was another child in the corner of the classroom throwing a fit, so she walked over to that child to resolve the issue. She said it only took her a few seconds to walk over to the other child and when she turned around towards the circle time rug, she saw child #2 pulling child #1's (left) arm. Teacher said she immediately told child #2 to stop pulling child #1's arm and she walked over to intervene and separate the children. She said child #1 was crying and favoring her arm. Teacher said she contacted Administrator at once and Administrator came into the classroom to assess the situation. Administrator stated she took child #1 to the office and placed ice on her arm. She said she checked the child for injuries, but could not visibly see anything wrong. Administrator stated she waited a few minutes to see if child #1 wanted to return to the classroom, but child #1 was still crying and seemed to be in pain. Administrator stated she then contacted child #1's parent and informed her of the situation. She said child #1's parent came to the facility within 20 to 25 minutes to pick up child #1 and she took child #1 to the doctor. Administrator stated she talked to child #1's parent later that day and was informed child #1 had a "pulled elbow" and she would be returning to school the next day. (continued on next page)

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Kathy Pacheco	TELEPHONE: (559) 341-5116
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2019

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: HIS KIDS PRESCHOOL	FACILITY NUMBER: 163808356
	VISIT DATE: 10/07/2019

NARRATIVE

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Administrator and Teacher stated child #1 and child # 2 are friends and they often play together. They said they have never seen aggressive issues with either child prior to the date of the incident. Administrator further stated, they usually like to have additional staff present, however, they had some staff out that day. LPA confirmed classroom #1 and the facility were within staff-ratios on the date of the incident.

Based on the information obtained, LPA determined Licensee handled the incident correctly and reporting requirements were met. After interviewing staff and children and reviewing facility records, LPA determined Licensee took appropriate measures to address child #1's injury. LPA further determined Licensee followed proper policies and procedures and no regulations were violated.

Per California Code of Regulations Title 22, Division 12, no deficiency cited during today's inspection.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Kathy Pacheco	TELEPHONE: (559) 341-5116
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2019

LIC809 (FAS) - (06/04)

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