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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334843019
Report Date: 06/23/2021
Date Signed: 06/23/2021 11:57:04 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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KURERA FAMILY CHILD CAREFACILITY NUMBER:
334843019
ADMINISTRATOR:KURERA,MALKANTHIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 974-9161
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:14CENSUS: 2DATE:
06/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Malkanthi Kurera, LicenseeTIME COMPLETED:
12:00 PM
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A case management visit is being conducted by Licensing Program Analyst, Giselle Carbullido in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 06/18/21. It indicates that a child sustained injuries while at the facility. At 10:00am LPA was greeted and allowed entry to the facility by Licensee.

Facility records were reviewed and interviews were conducted with Licensee, Parent and C1. Based on information gathered, the facility acted appropriately, and no violations have been identified.

At this time the facility took appropriate action by completing self-reporting requirements as required for UIRS: Notifying the Duty Officer within 24 hours and submitting the LIC624 to the Department of Social Services; notifying the parent and calling 911 for Emergency Medical Services.

There are no deficiencies cited. An exit interview was conducted, Notice of Site Visit issued, and a copy of this report was provided to the Licensee.

A copy of this report must be made available to the public for 3 years.

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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