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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330908141
Report Date: 02/23/2024
Date Signed: 02/23/2024 10:34:15 AM


Document Has Been Signed on 02/23/2024 10:34 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:V.I.P. TOTSFACILITY NUMBER:
330908141
ADMINISTRATOR:KINGSLEY A. BOULDINFACILITY TYPE:
850
ADDRESS:41915 E. ACACIA AVENUETELEPHONE:
(951) 652-7611
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:63CENSUS: 29DATE:
02/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Debbie Haney TIME COMPLETED:
09:27 AM
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On February 23, 2024, at 8:36 AM, Licensing Program Analyst (LPA) Anastasia Flores, arrived for the purpose of a case management visit in regard to an unusual incident report (UIR) received in our office. The UIR was received by the licensing agency on 01/31/24. It indicates the child #1 (C1) jumped from a stump causing injury. LPA toured the playground area where the child was injured, took photos, child #1(C1), was injured resulting in jumping from one stump to another, the stumps are made of soft plastic, the area is utilized for quiet activities. C1 is an active child, and the injury did not result in a lack of supervision.

Facility was observed, interviews conducted with two staff (S1, S2). Based on information gathered, the facility acted appropriately, and no violations have been identified. Staff immediately treated the child for injuries, called the parents and child was immediately picked up from facility. Administrator sent out an email to all staff the following day, reminding staff the area is for quiet activities, manufacturer of playground equipment was consulted to have the stumps fixed to make them softer.

An exit interview was conducted, and a copy of this report and appeal rights was provided to site supervisor, Debbie Haney.

SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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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