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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334807318
Report Date: 06/27/2023
Date Signed: 06/27/2023 04:40:49 PM


Document Has Been Signed on 06/27/2023 04:40 PM - 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:GROWING PLACE, TOO, THEFACILITY NUMBER:
334807318
ADMINISTRATOR:SPERAW, THEODORAFACILITY TYPE:
840
ADDRESS:4259 JURUPA AVENUETELEPHONE:
(951) 686-8134
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:60CENSUS: 23DATE:
06/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Julia MontanaTIME COMPLETED:
04:35 PM
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On 06/27/23 at 3:20 PM a case management visit was conducted in response to the receipt of an unusual incident report (UIR) from the facility on 06/09/23. It indicates a child sustained an injury (broken elbow) while attempting to climb monkey bars.

Facility records were reviewed, and interviews were conducted with Assistant Director, Teacher, Child and Parent. According to staff interviews conducted- child slipped while climbing monkey bars and struck elbow; first aid (ice) was applied, and parent notification was made for pick up. Child interview corroborated they were climbing on monkey bars, slipped on their shoelace and fell hurting their elbow. Parent confirmed facility staff notified them for pick up, they signed an injury report and facility recommended follow up care.

LPAs Carbullido and Ordones toured monkey bars in outdoor activity space and no hazards or debris were observed.

Based on information gathered, the facility acted appropriately, and no violations have been identified. Facility followed steps as outlined in program for parent notification; providing first aid; completing notification to Community Care licensing (CDSS) and submitting Unusual Incident report as required.

An exit interview was conducted, and LPAs Carbullido and Ordones provided Assistant Director, Julia Montana with a copy of this report, appeal rights and notice of site visit. 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: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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