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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334801219
Report Date: 12/23/2020
Date Signed: 12/23/2020 05:45:51 PM

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:LA PETITE ACADEMYFACILITY NUMBER:
334801219
ADMINISTRATOR:WENDY SERNAFACILITY TYPE:
840
ADDRESS:11100 COLLETT AVENUETELEPHONE:
(951) 688-1313
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:42CENSUS: 0DATE:
12/23/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Deanne McCashland, Regional DirectorTIME COMPLETED:
05:45 PM
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On 12/23/20 at 5:15pm a case management visit was conducted in response to the receipt of an unusual incident report (UIR) from the facility on 12/22/20 It indicates a child fell and sustained a cut to his forehead. Due to the executive order issued by Governor Newsom on March 16, 2020 regarding COVID-19 pandemic, this investigation was conducted via Tele-inspection (Facetime). LPA discussed purpose of tele visit which was to review video recording and records from the facility provided by DeAnne McCashland, Regional Director.

Facility video clip and records were reviewed. Based on information gathered, the facility acted appropriately, and no violations have been identified. (Direct Supervision and first aid was provided by the teacher; and facility notification to the parent and Community Care Licensing with submission of required documentation LIC624.)

An exit interview was conducted and LPA Carbullido provided Ms. McCashland, Regional Director with a copy of this report via email with an electronic “read receipt” request. The electronic read receipt of the emailed report acknowledges receipt of this report.


A copy of this report was emailed to Regional Director for this Tele-inspection on
December 23, 2020. This report must be made available to the public upon request for three years.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
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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