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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334840476
Report Date: 10/10/2019
Date Signed: 10/10/2019 11:48:06 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:LAKE ELSINORE UNIFIED SCHOOL DISTRICT CHILDCAREFACILITY NUMBER:
334840476
ADMINISTRATOR:FRIEDA BRANDSFACILITY TYPE:
850
ADDRESS:520 CHANEY STREETTELEPHONE:
(951) 253-7000
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:29CENSUS: 20DATE:
10/10/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Vicky FluellenTIME COMPLETED:
12:00 PM
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LPA Joanne Domingo arrived at the facility on a case management visit to follow-up on an unusual incident report submitted by the facility on 10/02/19. The incident occurred on 9/23/19. At the time of visit, LPA toured the facility activity table area, took census, and met with Lead Teacher, Vicky Fluellen to discuss the reported incident. During the visit, LPA also spoke with the Teacher who witnessed the incident as it took place. LPA Domingo attempted to interview the subject child
with the teacher, however the child was shy and did not want to talk

It was disclosed that during small group table activity on 9/23/19 at approximately 11:23am, Child #1 injured themselves when the child fell into the shelf of a bookcase located behind the table. Staff #1 stated there were approximately six children in their small group. The children were cleaning up and dismissed to go to the large group recall in the center of the room. Two children who were sitting next to each other had gotten up from their chairs at the same time. Child #1 had turned and in the process caught their leg into the chair leg of Child #2's chair. Child #1 fell forward and bumped their head on the shelf of the bookcase behind the table. Staff #1 immediately applied pressure to the child's forehead and cleaned up the child. Parent was notified and arrived shortly. Child was treated by a doctor and received stitches above the left eyebrow. The child returned to school a few days later.
Based on the information obtained during the visit, as well as an inspection of the furniture and equipment, there appeared to be no violations of Title 22 Regulations pertaining to the reported incident.

An exit interview was held with Lead Teacher, Vicky Fluellen. A Notice of Site visit was issued, along with a copy of this report. This report shall be public record for three years.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Joanne DomingoTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2019
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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