334844292-11-23-2020-09-CC-SRON-BVMVZJ-20201123155250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334844292
Report Date: 11/23/2020
Date Signed: 11/23/2020 03:53:24 PM

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:	FERNANDO FAMILY CHILD CARE		FACILITY NUMBER:	334844292
ADMINISTRATOR:	WEERAHENNEDIGE-FERNANDO, N		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(657) 256-8388
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92508
CAPACITY:	14	CENSUS: 12	DATE:	11/23/2020
TYPE OF VISIT:	Case Management - Incident	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Nimaly Fernando, Licensee		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	November 23, 2020 Due to COVID-19, Licensing Program Analyst (LPA) Sharleen Robinson conducted a Tele-inspection with Licensee Nimaly Fernando, the purpose of the visit is to follow up on an unusual incident report that was submitted by the facility on November 21, 2020. LPA met with Licensee Nimaly Fernando via FaceTime to discuss the reported incident. There were 12 children in care. Licensee toured LPA through the facility (virtually ) where the incident occurred, interviews conducted and records reviewed. The Licensee self-reported, that on or about November 17, 2020 at approximately 9:00am Child #1 pulled Child #2 left arm and hand trying to pull puzzle pieces out of Child #2 left hand. Licensee provided first aide to the child and notified the child's representative. The child's representative took the child to seek medical attention on November 17, 2020. The child was diagnosed with a sprained left arm/shoulder. The child returned to the facility without restrictions on November 19, 2020. On or about November 21, 2020 the child was experiencing pain therefore, the child's representative took the child to seek additional medical attention. The child was diagnosed with a cracked collar bone. The child returned to the facility November 23, 2020. The child has to wear a sling on their left arm for two weeks. When the incident occurred Staff #1 was supervising 3 children at a table playing with puzzle pieces. Staff #1 was standing at the table passing out puzzle pieces to children. Staff #1 witnessed when Child #1 pulled Child #2 left arm and hand however, Staff #1 did not anticipate Child #1 pulling Child #2 left arm and hand. Staff #1 could not get to the children in time to prevent the incident as it was unforeseen. After the incident Staff #1 verbally redirected Child #1 and Licensee who was standing nearby immediately comforted Child #2 and provided first aide to the child. Children were unable to participate in the interview due to being unavailable. See LIC809C for the remainder of the report>>>>>>>>>>>>>>>>

SUPERVISOR'S NAME: Kimberly Williams	TELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Sharleen Robinson	TELEPHONE: (951) 233-7183
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: FERNANDO FAMILY CHILD CARE	FACILITY NUMBER: 334844292
	VISIT DATE: 11/23/2020

NARRATIVE

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Based on the information obtained during the visit, there appeared to be no violation of Title 22 Regulations pertaining to the reported incident.

An exit interview was conducted via FaceTime, LPA Robinson provided the licensee with a copy of this report via email, LPA asked the licensee to acknowledge receipt of the email. An electronic “read receipt” was also attached. The electronic read receipt of the emailed report acknowledges receipt of this report. A copy of this report and notice of site visit was emailed to the Licensee during this Tele-inspection on November 23, 2020.

No deficiencies sited at this time. A copy of this report must be made available for the next three years.

SUPERVISOR'S NAME: Kimberly Williams	TELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Sharleen Robinson	TELEPHONE: (951) 233-7183
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020

LIC809 (FAS) - (06/04)

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