191500006-5-5-2023-33-CC-VMGA-CRC28C-20230428171006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191500006
Report Date: 03/28/2023
Date Signed: 05/05/2023 02:15:24 PM

Document Has Been Signed on 05/05/2023 02:15 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	OPTIONS SURROUND CARE-BLANDFORD		FACILITY NUMBER:	191500006
ADMINISTRATOR:	BERTHA SEQUEIDA		FACILITY TYPE:	840
ADDRESS:	18605 LINCROFT STREET		TELEPHONE:	(626) 913-0603
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 40	TOTAL ENROLLED CHILDREN: 40	CENSUS: 19	DATE:	03/28/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:58 PM
MET WITH:	Substitute Trisha Cuomo		TIME COMPLETED:	05:15 PM

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

*** This is an Amended report to clarify that the Case Management visit was completed on 04/28/23 and not 03/28/23.********

Licensing Program Analyst (LPA) Veronica Martinez Garza conducted an unannounced Case Management inspection at the above facility on 04/28/23 at 01:58 pm due to an incident that was reported to the Department on March 13, 2023. Due to COVID-19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPA met with Substitute, Trisha Cuomo who guided LPA on a tour of the facility. Census was taken.

On March 14, 2023, an unusual incident report was made to the department regarding an incident that involved a child who sustained injury on March 13, 2023, that required medical attention. The incident happened approximately between 04:00 pm – 04:30 pm. This program is located on the premises of Blandford Elementary School.

During this inspection, LPA interviewed Staff #1 (S1), Child #1 (C1), C2, C3, obtained a copy of the children’s sign in/out sheets for March 13, 2023, and observed the area where the incident took place. Based on the sign in/out sheets 14 children were present with 2 staff. LPA took pictures of the area where the incident took place. Per S1, she was standing in an area where all children were visible and observed C1 fall. S1 immediately went to check on C1 who was crying. S1, provided C1 with an ice pack and contacted C1s dad who arrived within 5 - 6 minutes. C1 was taken to the ER and the X-ray showed that C1 had a fracture on his left arm. Per C1, he had previously fallen 2 times and had landed on the same left arm during school hours. During program, C1 was accidentally bumped by C3 when they were playing handball which caused C1 to fall and slip on the leaves that were on the floor. C1 landed on his left arm for the third time on that day. C1 returned to the program the next day with an arm sling. Dr’s restrictions for C1 were no PE for 2-3 weeks.

Page 1 of 2

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: OPTIONS SURROUND CARE-BLANDFORD	FACILITY NUMBER: 191500006
	VISIT DATE: 03/28/2023

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
32

Prior to this incident, it had rained the week prior and it was windy which resulted in leaves falling from nearby trees. Elementary school outdoor is maintained by the school Janitor. Staff are taking precautionary measures to ensure that the children’s outdoor area is safe. LPA advised facility to contact district for maintenance upkeep.

Based on interviews and documents received, it is unknown if C1 had sustained an injury previously when C1 fell on 2 occasions during school hours and on the third time C1 fell in the program aggravated his injury where it resulted in a fracture. This accident could not have been prevented since C3 bumped into C1. The facility followed all proper procedures; Staff administered first aid, child’s parent were notified, and incident report was sent in a timely manner.

There are no deficiencies being cited.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Substitute Trisha Cuomo. Appeal rights were provided.

Page 2 of 2

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2