191501798-7-9-2021-33-CC-BBEL-C4S3K3-20210709181827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191501798
Report Date: 07/09/2021
Date Signed: 07/09/2021 06:18:36 PM

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:	ABILITY FIRST		FACILITY NUMBER:	191501798
ADMINISTRATOR:	JULIE MARTIN		FACILITY TYPE:	840
ADDRESS:	480 SOUTH INDIAN HILL BLVD.		TELEPHONE:	(909) 621-4727
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	58	CENSUS: 7	DATE:	07/09/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Director Julie Mariin		TIME COMPLETED:	06:15 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	An unannounced in-person Case Management-Incident inspection was conducted on this date by Licensing Program Analysts (LPAs) Emiko Bell and Steven Rodriguez to follow up on an Unusual Incident which occurred on 07/01/21 and was reported via phone on 07/02/21 and via email on 07/07/21 to Community Care Licensing (CCL) . Upon LPA's arrival at 09:00 am, LPAs were greeted at the door by Administrative Assistant Jane Garcia, who took LPAs' temperatures. LPAs then answered COVID-related questions on "Dr. Owl" before washing their hands. At 09:20, Director Julie Martin arrived; at 09:25, the purpose of the inspection was announced to Program Supervisor Bonita Ramos before she began guiding LPAs on a tour of the facility; at 09:35, Director Martin took over guiding LPAs on a tour of the facility. Census: In room 1, there was one staff with four children and in room two, there was one staff with three children. Staff-child ratio was met. During today's inspection, interviews were conducted with one minor and three staff and documentation in the form of the "After School ProgramParent Handbook 2019," copies of the First Aid/CPR certificates for Staff 2 and Staff 3, the "Patient Visit Information" for Child 1, the "New Client Fact Sheet" for Child 1, the "Participant Referral Screening/Tracking Form" for Child 1, the "Special Incident Report" and the "Case Note" for the incident were obtained.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ABILITY FIRST	FACILITY NUMBER: 191501798
	VISIT DATE: 07/09/2021

NARRATIVE

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The Unusual Incident which occurred is that at around 02:00 pm, a child slipped and fell on a hula hoop, hitting the right side of their head, sustaining a bump and a mild concussion. By all accounts, the group was playing with hula hoops which were laid out flat on the ground, like in the shape of a flower. Child 1 (C1) was then taken to the bathroom by Staff 2 (S2). According to S2, upon return to the classroom, C1 ran to the back of the classroom, then ran towards the middle of the classroom, where there were hula hoops still on the floor, and slipped and fell on a hula hoop; according to S3, C1 began playing in the hula hoops, accidentally slipping and falling on the edge of one while trying to jump in the midst of them.

After slipping and falling, an ice pack was applied to C1's head, and the hula hoops were picked up. An art activity was then laid out for the participants to work on. S3 observed that C1 was not acting normal, appearing very calm and participating in the art activity, though not wanting to play with the activity. About 20-40 minutes later, C1 got up and vomited. The parent of C1 was then notified to come pick C1 up. Parent arrived at around 03:00. When S1 got off of a meeting, S1 was notified of the incident. By 06:40 pm, parent reported that as C1 had vomited twice more, parent and C1 were at the Emergency Room, where C1 was diagnosed with a mild concussion. The "Patient Visit Information" does not document the diagnosis, only advising parent to follow up with the primary care physician in 2-3 days. Parent kept the child home on 07/02/21, but C1 returned to the Center on 07/06/21. When interviewed on 07/09/21, C1 still had a bump on their head.

The parent of C1 stated that C1 is a known runner; however, documentation of this was not found in C1's file. Per S3, S4 had once verbally mentioned that C1 needs to be reminded to have walking feet. Per S1 and S3, C1 is observed to run into classrooms or run to their friends, though not to run out of classrooms. S2 was not familiar with C1, as they are not normally in the

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ABILITY FIRST	FACILITY NUMBER: 191501798
	VISIT DATE: 07/09/2021

NARRATIVE

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classroom of C1.

Per S3, the incident was documented on a "Case Note" as a minor incident because C1 did not lose consciousness. The incident was upgraded to a "Special Incident Report" after C1 vomited. Per S3, the parent was not notified immediately because parents are notified only when a participant vomits or runs a fever. However, according to page 19 of the "After School Program Parent Handbook," "AbilityFirst staff will attempt to notify a parenr or authorized representative..promptly if your child becomes ill or is injured with something more serious than a minor cut or scratch."

Though the Center is not being issued a citation today for the incident, LPAs are issuing a technical violation for not abiding by their own Parent Handbook and notifying the parent immediately of the head injury. After the incident, Center began holding the hand or arm of C1 during transitions and is encouraging participants to pick up items not in use after they are played with. When asked if holding the arm/hand of C1 has made a difference, all three staff interviewed said yes.

Upon receipt, Director Martin shall post the Notice of Site Visit. The Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100 civil penalty.

An exit interview was conducted with, and a copy of the report has been signed by and provided to Director Julie Martin.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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