330911137-12-6-2022-10-CC-SHAA-CLUQYU-20221206113544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 330911137
Report Date: 12/06/2022
Date Signed: 12/06/2022 11:35:51 AM

Document Has Been Signed on 12/06/2022 11:35 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:	SENECA ELEMENTARY PRESCHOOL		FACILITY NUMBER:	330911137
ADMINISTRATOR:	THELMA SANCHEZ		FACILITY TYPE:	850
ADDRESS:	11615 WORDSWORTH ROAD		TELEPHONE:	(951) 571-4716
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY:	30	CENSUS: 9	DATE:	12/06/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Thelma Sanchez		TIME COMPLETED:	11:45 AM

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On date and time listed, Licensing Program Analyst (LPA) Sumayya Habeebulla arrived at the facility to conduct a Case Management visit in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the department on 11/17/22. The incident involved child #1 falling off the slide during outdoor play time.

See Confidential Names list (LIC811).

LPA interviewed S1 and S2 and toured the playground. As per S1, C1 currently has a cast with a boot on and will only return to the facility in January of 2023.

On 11/14/22 during play time, C1 came down the slide and C2 immediately followed down behind him. C1 was accidently pushed off the slide by C2 and as per the staff observation it was not a thrust but more of a gentle glide. C1 fell onto the woodchips and began to cry. S1 stated that she always reminds her students to slide down one at a time. S1 was standing right in front of the slide as per the observations of S1 and S2, the fall was not a hard fall. S1 took C1 inside the classroom and parents were notified. The teachers gave C1 an ice pack to be placed on his leg. C1 was crying in pain and would not let teachers check his leg. Parent stated the grandmother would pick the child up. Staff contacted the grandmother when she hadn’t arrived even after 30 mins and Grandmom stated she is on her way. Grandmother arrived after 50 mins to an hour after the incident. C1 was taken to the doctor the following day since he was still in pain. The parent reported to S2 that C1 has a Cyst on his bone and probably the fall had agitated it. As per the Parent the doctor monitors it every 6 months. Parent also stated to S2 that C1 has had a cast previously. S2 is not aware of which leg the child had a cast on.

See LIC 809C for continuation

SUPERVISOR'S NAME: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: SENECA ELEMENTARY PRESCHOOL	FACILITY NUMBER: 330911137
	VISIT DATE: 12/06/2022

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Based on information gathered, the facility acted appropriately, and no violations have been identified. The School Principal submitted an unusual incident report, evaluated the playground where the incident occurred, interviewed teachers, and communicated with parents and immediately reported the incident to this agency.

NO DEFICIENCIES WERE CITED DURING THIS VISIT.

An exit interview was conducted, and this report was reviewed with Facility Representative Ms. Thelma Sanchez. Appeal rights were discussed and provided during the exit interview.

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

SUPERVISOR'S NAME: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

LIC809 (FAS) - (06/04)

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