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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830521
Report Date: 10/10/2023
Date Signed: 10/10/2023 12:38:23 PM


Document Has Been Signed on 10/10/2023 12:38 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: 56DATE:
10/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Alondra Rios and Vanessa JaraTIME COMPLETED:
12:45 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 unusual incident reports (UIRs) from the facility. The UIR was received by the licensing agency on 10/09/23. The UIR indicated a staff grabbed a child by the arm while in care on 10/05/23.

At time of visit, LPA toured the facility, took census, reviewed records, and conducted interviews with pertinent parties including four staff and one child.



Pertinent parties reported teachers may offer their hand for assistance and to give hugs or high fives. All interviews denied any teacher grabbing a child by the arms.

Based on the information obtained during the visit, the facility acted appropriately, and no violations have been identified pertaining to this incident. Facility completed reporting requirements as required by CCR regulations for UIRS (Telephone notification to Duty Officer and submission of LIC624) to the Department of Social Services. Facility maintained staff to child ratios for supervision and communication with authorized representative.

Appeal rights issued and discussed with Director Alondra Dominguez and Vanessa Jara (Jauregui) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of this report and Notice of Site Visit were provided to the Director Alondra Dominguez and Ms. Vanessa Jara. 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: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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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