334844855-9-29-2022-09-CC-GCAO-CJQU4G-20220929151508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334844855
Report Date: 09/29/2022
Date Signed: 09/29/2022 03:15:14 PM

Document Has Been Signed on 09/29/2022 03:15 PM - It Cannot Be Edited

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:	LEARNING EXPERIENCE, THE		FACILITY NUMBER:	334844855
ADMINISTRATOR:	BELEN ACOSTA		FACILITY TYPE:	830
ADDRESS:	515 ALESSANDRO BLVD.		TELEPHONE:	(951) 386-2560
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92508
CAPACITY: 32	TOTAL ENROLLED CHILDREN: 32	CENSUS: 23	DATE:	09/29/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Belen Acosta, Director		TIME COMPLETED:	03:30 PM

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On the date and time listed above, 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 09/23/22. It indicates an infant sustained an injury while running to retrieve a toy from a shelf.

Facility records were reviewed, and interviews were conducted with Staff ( Director, Teacher) and Parent.

According to staff interviews conducted, There were 4 infants present with 1 staff. Staff interviews reported infant was running to retrieve a toy doll off the shelf when they fell and struck their face on the middle shelf resulting in a cut between the eyes. Staff provided first aid of light pressure and ice and cleaned the wound. Director interview reported Parents were called for pick up and that the cut stopped bleeding after a few minutes. Staff interviews reported Parent called later in the afternoon noting the infant required a couple of stiches and would return to the facility the following Monday.

Parent interview stated facility notified them in a timely fashion, provided care until they picked up their infant, and provided an incident report. Parent stated they understood accidents happen and confirmed infant has returned to care at the facility.
At 2:20PM, LPA toured and obtained photos of the infant indoor activity area. LPA did not observe any hazards present in the classroom or on any of the flooring. The shelf is low and was stable against the wall.

Based on information gathered from interviews and records, the facility acted appropriately, and no violations have been identified. Facility completed reporting requirements as required by CCR regulations for Unusual Incident Reports (Telephone notification to Duty Officer and submission of

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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: LEARNING EXPERIENCE, THE	FACILITY NUMBER: 334844855
	VISIT DATE: 09/29/2022

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LIC624) to the California Department of Social Services. Facility contacted parent for additional medical follow up, maintained staff to infant ratios for supervision and has age appropriate furniture within the classroom.

An exit interview was conducted, and LPA Carbullido provided the Director, Belen Acosta with a copy of this report, appeal rights and notice of site visit during today’s visit.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC809 (FAS) - (06/04)

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