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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830521
Report Date: 05/16/2023
Date Signed: 05/16/2023 01:45:08 PM


Document Has Been Signed on 05/16/2023 01:45 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:FSA-MAGNOLIA CDCFACILITY NUMBER:
334830521
ADMINISTRATOR:LESLIE COXFACILITY TYPE:
850
ADDRESS:8172 MAGNOLIA AVE.TELEPHONE:
(951) 353-0129
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:156CENSUS: 72DATE:
05/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Alondra DominguezTIME COMPLETED:
01:45 PM
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On the date and time listed above, 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 05/09/2023. It indicated that staff used their foot to tap/rock a child to sleep.

At time of visit, LPA toured the facility, took census, reviewed records and conducted interviews with children, staff and parent. Due to conflicting information reported, LPA was unable to determine if a violation occurred.



Based on the information obtained during the visit, at this time, there appeared to be no violations of Title 22 Regulations pertaining to the reported incident.

An exit interview was held with Director Alondra Dominguez. A Notice of Site visit and appeal rights were issued, along with a copy of this report.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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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