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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334840382
Report Date: 07/02/2019
Date Signed: 07/02/2019 09:41:17 AM

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:CRAYON RANCH CHILD CARE CENTERFACILITY NUMBER:
334840382
ADMINISTRATOR:VIVANCO, CARMENFACILITY TYPE:
840
ADDRESS:25145 VISTA MURRIETA ROADTELEPHONE:
(951) 677-3303
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:52CENSUS: 21DATE:
07/02/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Carmen Vivanco, DirectorTIME COMPLETED:
09:50 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 June 20, 2019. It indicates that on June 19, 2019 child #1 (C1) attempted to fall into a bean bag and in the process C1 hit head on the window seal which resulted in a cut above the right eyebrow.

Facility records were reviewed and C1, Staff #1 (S1) and Staff #2 (S2) were interviewed. Based on information gathered, the facility acted appropriately and no violations have been identified. Staff cleaned the wound and applied pressure and immediately contacted the child's parents.

An exit interview was conducted and a copy of this report was provided to facility staff.

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Timeka ReedTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019
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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