330910781-10-21-2022-09-CC-GCAO-CKENKW-20221021103238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 330910781
Report Date: 10/21/2022
Date Signed: 10/21/2022 10:32:45 AM

Document Has Been Signed on 10/21/2022 10:32 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	JUSD/MISSION BELL ELEMENTARY STATE PRESCHOOL		FACILITY NUMBER:	330910781
ADMINISTRATOR:	KATRINA BROOKS		FACILITY TYPE:	850
ADDRESS:	4020 CONNING STREET RM. 5		TELEPHONE:	(951) 222-7850
CITY:	JURUPA VALLEY	STATE: CA	ZIP CODE:	92509
CAPACITY:	24	CENSUS: 9	DATE:	10/21/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Katrina Brooks		TIME COMPLETED:	10:40 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 the date and time listed above, a case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 10/04/2022. It indicates a child sustained an injury while running outdoors. On 10/14/22 an initial visit was conducted, and LPA reviewed records and conducted interviews with Staff and Parent. According to staff interviews conducted, there were 15 children present with 3 staff. Staff interviews reported child and a peer were running alongside each other, collided and fell onto the grass. Staff checked child’s arm and did not note any swelling or bruising. Staff provided first aid (ice pack) for child’s arm and asked child if they were okay to play. Child responded yes, denied any further pain and returned ice pack after five minutes. Child resumed participation in scheduled activities (small group, indoor/outdoor free play and snack) until pick up. Parent interview noted that the child’s arm was swollen at pick up and took child to the doctor. Parent updated facility on medical status and appointments. Parent received an ouch report but noted there was a delay due to dismissal activity in progress and communication between teachers. Child interview reported they fell on the grass after running with another child. Child stated they had an ice pack then went to play and have snack. During the course of interviews, staff disclosed that due to child’s participation in activities without any complaints of pain or injury; they did no further checks after initial incident; including a delay in notification to parent. LPA provided technical advisories on CCR Health related services 101226 and 101226.3 Observation of the Child. See LIC9102TV.

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle Carbullido	TELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: JUSD/MISSION BELL ELEMENTARY STATE PRESCHOOL	FACILITY NUMBER: 330910781
	VISIT DATE: 10/21/2022

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

On 10/14/22 at 10:25 AM, LPA toured and obtained photos of the outdoor activity area where incident happened. LPA did not observe any hazards on the ground. The grass area was open with even terrain.

Based on information gathered from interviews and records, the facility acted appropriately, and no violations have been identified. Facility completed reporting requirements as required by CCR regulations for Unusual Incident Reports (submission of LIC624) to the California Department of Social Services. Facility maintained staff to children ratios for supervision (3 staff to 15 children); outdoor surfaces were free from debris and hazards, and maintained communication with parent.

An exit interview was conducted, and LPA Carbullido provided Katrina Brooks with a copy of this report, appeal rights and notice of site visit during today’s visit.

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle Carbullido	TELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2