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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334820096
Report Date: 04/24/2024
Date Signed: 04/24/2024 05:17:12 PM


Document Has Been Signed on 04/24/2024 05:17 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:MELODY LANE CHILDREN'S CENTERFACILITY NUMBER:
334820096
ADMINISTRATOR:JULIE BACAFACILITY TYPE:
840
ADDRESS:9191 COLORADO AVENUETELEPHONE:
(951) 352-2161
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:17CENSUS: 13DATE:
04/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Julie Baca and Janice RandolphTIME COMPLETED:
04:30 PM
NARRATIVE
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On the date and time listed above a case management visit was completed by Licensing Program Analyst (LPA) Giselle Carbullido due to deficiencies found during the course of another inspection.
1) Reporting Requirements: Facility did not report to Community Care Licensing an unusual incident that occurred on 12/28/2023 by telephone or fax to the department by the next business day (24 hours). SEE LIC 809D for the deficiency cited.
2) Child Record’s: Facility did not keep a child’s information confidential. See LIC9102TV technical advisory.
The Director and Licensee were provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights.
An exit interview was conducted, a copy of this report and Notice of Site Visit were provided to the Director and Licensee. LPA observed the Notice of Site Visit form was posted by staff. THIS REPORT MUST BE 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: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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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Document Has Been Signed on 04/24/2024 05:17 PM - It Cannot Be Edited

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 CHILDREN'S CENTER
FACILITY NUMBER: 334820096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2024
Section Cited
CCR
101212(d)(1)(C)

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Reporting requirements: 101212(d)((1)(C)-Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement is not met as evidenced by:
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Director will submit an unusual incident report for 12/28/23 by POC due date 04/26/2024 or earlier to the department.
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Based upon LPA record review, the facility did not report an incident occurring on 12/28/23 regarding a staff/child interaction. This is a potential health and safety risk to 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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
LIC809 (FAS) - (06/04)
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