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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334816521
Report Date: 06/21/2019
Date Signed: 06/21/2019 12:11:51 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:LEE FAMILY CHILD CAREFACILITY NUMBER:
334816521
ADMINISTRATOR:LEE, OMARRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 242-8872
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY:14CENSUS: 8DATE:
06/21/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Omarra LeeTIME COMPLETED:
12:15 PM
NARRATIVE
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A Case Management Visit is being conducted in response to the receipt of the Unusual Incident Report (UIR) from the facility. Initial visit was 1/22/19. Licensing Program Analyst (LPA). Yolanda Jackson conducted a visit to the facility for the purpose of delivering the findings of the investigation. LPA met with the Licensee, Omarra Lee. LPA toured the facility and observed 8 children present.

During the course of an investigation conducted by Community Care Licensing Investigations Branch Investigator Wilfredo Vasquez, the following violation of Lack of Supervision was identified: A Staff Member #1 left a child #1 unattended for a brief period of time strapped to a booster chair on top of the kitchen counter. The booster chair tipped over and the child #1 fell to the ground. The child #1 suffered serious injuries. The paramedics were called and after 4 hours of observation at the hospital, the child #1 was released without complications. It was listed on the Warning Label on the booster chair that it must be strapped to a chair and that the child must never be left unattended to prevent serious injury or death to a child to sliding out, falls or tipping over.

See 809D for cited deficiencies for the California Code of Regulations, Title 22, Div. 12

An exit interview was held, Appeal rights, along with a copy of this report was provided at time of the visit.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 784-4200
LICENSING EVALUATOR NAME: Yolanda JacksonTELEPHONE: (951) 201-1991
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
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: LEE FAMILY CHILD CARE
FACILITY NUMBER: 334816521
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2019
Section Cited
CCR
102417(a)
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OPERATION OF A FAMILY CHILD CARE HOME. The licensee shall be present in the home and shall ensure that children in care are supervised at all times. This Requirement was not met as evidenced by:
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Due to the seriousness of this violation Enhanced Civil Penalties determination is pending.
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A staff member #1 left a child unattended for a brief period of time strapped to a booster chair on top of the kitchen counter. The booster chair tipped over and the child fell to the ground.
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The child suffered serious injuries. This poses an immediate risk to the Health, Safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 784-4200
LICENSING EVALUATOR NAME: Yolanda JacksonTELEPHONE: (951) 201-1991
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
LIC809 (FAS) - (06/04)
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