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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334812819
Report Date: 08/15/2024
Date Signed: 08/15/2024 03:08:32 PM


Document Has Been Signed on 08/15/2024 03:08 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:FSA-HEMLOCK CDCFACILITY NUMBER:
334812819
ADMINISTRATOR:CYNTHIA OLIVAS FLETCHERFACILITY TYPE:
850
ADDRESS:23270 HEMLOCK AVE.TELEPHONE:
(951) 243-3192
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:110CENSUS: 56DATE:
08/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Cynthia Olicas, DirectorTIME COMPLETED:
03:20 PM
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On Thursday, August 15, 2024 at approximately 11:08 AM, Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced Case Management inspection to follow-up on an Unusual Incident Report (UIR) received by Community Care Licensing CCL on July 31, 2024. LPA met with Director Cynthia Olivas-Fletcher (S1) and toured the facility. LPA received evidence related to the incident, interviewed the Director, four staff members, a confidential witness, and Child One (C1) during this investigation.

On 07/31/2024, CCL received information via UIR that on 07/17/2024, Staff Two (S2) allegedly pinched Child One (C1). On the same report dated 07/31/2024, CCL received information that on 07/22/2024, Staff Three (S3) hit C1. During the course of the investigation, LPA identified Staff Four (S4), and Staff Five (S5) as possible witnesses. See Confidential Names list (LIC811). Records review confirmed that the facility was operating within proper staff to child ratio.

Based on information gathered, the facility acted appropriately, and no violations have been identified.

Director Cynthia Olivas-Fletcher submitted an unusual incident report, interviewed teachers and C1, and communicated with C1's guardian and immediately reported the incident to this agency. An exit interview was conducted where a copy of this report was reviewed with and provided to Director Cynthia Olivas-Fletcher along with a copy of the Appeal Rights. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 505-6334
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 204-4913
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
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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