334819985-3-4-2024-09-CC-GCAO-D32NTW-20240304094525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334819985
Report Date: 03/04/2024
Date Signed: 03/04/2024 09:45:29 AM

Document Has Been Signed on 03/04/2024 09:45 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	MELODY LANE CHILDRENS CENTER		FACILITY NUMBER:	334819985
ADMINISTRATOR:	JULIE BACA		FACILITY TYPE:	850
ADDRESS:	9191 COLORADO AVENUE		TELEPHONE:	(951) 352-2161
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	73	CENSUS: 16	DATE:	03/04/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Janice Randolph		TIME COMPLETED:	09:45 AM

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A case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 02/27/2024. It indicates a child cut their finger on landscape material during outside activity and facility took preventive measures.

LPA reviewed records and conducted interviews. A tour of the facility was also conducted to verify preventive measures, removal of bark, were completed.

According to Licensee interview, facility ordered new rubber bark to replenish the older rubber bark. A child fell while running and cut their finger requiring first aid. The facility worked with the gardener and discovered the new landscape material had some sharp pieces; the bark was immediately removed from the playground.

During the tour at 8:23AM, LPA obtained a photo of the outdoor activity area where the incident happened. LPA verified landscape material was removed and observed the facility also had sand underneath play structures.

Based on information gathered, the facility acted appropriately, and no violations have been identified. Facility removed new landscape material that was discovered to have some sharp pieces. First aid was provided for child’s cut and written notification was

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle Carbullido	TELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

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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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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MELODY LANE CHILDRENS CENTER	FACILITY NUMBER: 334819985
	VISIT DATE: 03/04/2024

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provided to the parent. Facility completed reporting requirements as required by CCR regulations for Unusual Incident Reports (submission of LIC624) to the California Department of Social Services.

A technical advisory was issued to review that outdoor activity space is maintained in a safe condition for any activities planned per CCR Title 22 regulation: 101238.2(d)(1) See LIC9102TV.

An exit interview was conducted, and LPA Carbullido provided the Licensee with a copy of this report, appeal rights and notice of site visit during today’s visit

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle Carbullido	TELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC809 (FAS) - (06/04)

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