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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334843050
Report Date: 07/19/2019
Date Signed: 07/19/2019 08:36:13 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:PAGE FAMILY CHILD CAREFACILITY NUMBER:
334843050
ADMINISTRATOR:PAGE, ANNETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 552-0650
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY:14CENSUS: 1DATE:
07/19/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:40 AM
MET WITH:Anette Page, Licensee TIME COMPLETED:
08:40 AM
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Licensing Program Analysts (LPAs) Sharleen Robinson, Susan Brewer and Mariah McCarty arrived at the facility for the purpose of conducting a case management follow-up visit, regarding an unusual incident report that was submitted by the facility on July 16, 2019. The unusual incident report is regarding a possible personal rights violation.

LPA met with Licensee Annette Page. LPAs toured the facility (there was 1 child in care) conducted interviews, and reviewed records.

Licensee reported the following unusual incident: July 16, 2019 at approximately, 9:26am there were two day care children in care, one of licensees dogs was sleeping under the island area in the kitchen, “for no reason Child#1 kicked the dog in the head several times” Licensee separated Child#1 from the dog. Per Licensee the child has struck other children in the past, as a result Licensee terminated services July 16, 2019. When the Child’s authorized representative arrived the child stated “puppy bit me” per licensee “the child was not bit, instead the child obtained a small scratch approximately 1/8” long as a result of playing in wood chips located in the backyard. Licensee admits to not creating an unusual incident report or providing first aide as there was no break in the skin and no medical attention required, licensee was not aware of the scratch until it was brought o her attention.

During interviews LPAs learned other children did not witness Child#1 kicking the dog or being bitten by the dog. It was also disclosed that the dogs do scratch and bite. Licensee stated the dogs and cats don't scratch children.

As a result of the incident Licensee agrees to ensure her pets are in their crates, on a leash or outside when the children are inside and or inside when the children are outside.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 784-4200
LICENSING EVALUATOR NAME: Sharleen RobinsonTELEPHONE: (951) 782-4954
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PAGE FAMILY CHILD CARE
FACILITY NUMBER: 334843050
VISIT DATE: 07/19/2019
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Based on conflicting information obtained during record reviews and interviews, LPAs could not determine if there was a violation of Title 22 regulations pertaining to the reported incident, at this time.

An exit interview was held with Licensee Annette Page. A Notice of Site visit was issued, along with a copy of this report. No deficiency cited, at this time.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 784-4200
LICENSING EVALUATOR NAME: Sharleen RobinsonTELEPHONE: (951) 782-4954
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
LIC809 (FAS) - (06/04)
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