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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910254
Report Date: 08/09/2019
Date Signed: 08/09/2019 09:29:43 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CITY OF COLTON/PAUL ROGERS ELEMENTARY SCHOOLFACILITY NUMBER:
360910254
ADMINISTRATOR:CHRISTOPHER RYMERFACILITY TYPE:
840
ADDRESS:955 W. LAURELTELEPHONE:
(909) 370-4162
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY:62CENSUS: 0DATE:
08/09/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Michelle Benitez, Site SupervisorTIME COMPLETED:
09:40 AM
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Licensing Program Analyst's (LPA), Otsanya Cameron and Carlos Martinez, arrived to follow up on an unusual incident report that was submitted to Licensing by the facility on 05/14/19. LPA met with the MIchelle Benitez, Site Supervisor, who allowed LPA's entry into facility. Nancy Hernandez, Staff, was also interviewed this date.

According to Hernandez, Child #1 was playing on a play structure and was observed jumping from the monkey bars to a platform. While playing, Child #1 attempted to jump from the platform onto the monkey bars when she suddenly slipped and fell to the ground, consequently, injuring her arm. When she got up, Staff inquired if she was okay, and the child replied she was fine. A few minutes later, after the incident occurred, the father arrived on premises and the child went to greet him, at which point, she complained of pain to her arm. Hernandez indicated that she was immediately provided first aid and was given ice, however, the father decided to take the child to the hospital where she was diagnosed with a broken arm.

LPA Martinez determined that staff acted appropriately and provided adequate care and supervision as required. In addition, LPA Martinez noted that the facility was within ratio and adequately staffed.

An exit interview was conducted, and a copy of this report was provided.

A copy of this report must be made available to the public, at the facility site, for 3 years.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Carlos MartinezTELEPHONE: (951) 782-4936
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019
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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