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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911004
Report Date: 05/06/2022
Date Signed: 05/06/2022 12:33:03 PM


Document Has Been Signed on 05/06/2022 12:33 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:FUSD/LIVE OAK ELEMENTARYFACILITY NUMBER:
360911004
ADMINISTRATOR:DARCY WHITNEYFACILITY TYPE:
850
ADDRESS:9522 LIVE OAK AVENUETELEPHONE:
(909) 357-5640
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:48CENSUS: 8DATE:
05/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:
Rosiario Alejandrez/Teacher		TIME COMPLETED:
12:50 PM
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On 5/6/22 at 11:42 am, Licensing Program Analyst (LPA) Patricia Berry conducted a case management incident inspection. LPA was granted access into the facility and met with the teacher. LPA toured facility and took a census. LPA interviewed staff, C1 and parent.

On 4/26/22 S1 self reported and incident that occurred with C1 who tripped and fell on the playground around 12:45 pm, S1 stated according to the parent the hand was fractured. S1 stated she was not aware of any swelling, until 1:20 pm. S1 stated she called the nurse to the classroom, and the nurse assessed C1. S1 stated C1 could move the hand. S1 stated the nurse would call the parent which is the protocol at the facility. S1 stated the nurse called the parent after the parent picked up C1.

Based on the information received there does not appear at this time to be a violation of Title 22 regulations. The incident appeared to have been an accident.



Exit interview with teacher, report, appeal rights, notice of site visit and confidential names list provided to the teacher.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Patricia BerryTELEPHONE: (951) 782-4952
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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