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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364800492
Report Date: 10/04/2022
Date Signed: 10/04/2022 03:40:46 PM


Document Has Been Signed on 10/04/2022 03:40 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:YMCA/SMILEY SCHOOL AGE SITEFACILITY NUMBER:
364800492
ADMINISTRATOR:LILLIANA SANDOVALFACILITY TYPE:
840
ADDRESS:1210 W. CYPRESS AVENUETELEPHONE:
(909) 735-6890
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:75CENSUS: 38DATE:
10/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Allison RosenthalTIME COMPLETED:
03:45 PM
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On 10/04/2022, Licensing Program Analyst (LPA) Destinee Hogue arrived at the facility to conduct a case management inspection. A case management inspection is being conducted in response to the receipt of an unusual incident report (UIR). The UIR was received by the licensing agency on 09/21/2022. During this inspection, LPA toured the facility including the playground were incident took place, pictures were taken, and additional documents were gathered. Census of children present was taken on this date, along with facility association. LPA Hogue discussed the following with Teacher, Allison Rosenthal:

The facility reported, on or about September 16, 2022, while playing on the outdoor play structure, a child(ren) tripped on his/her shoe lace, causing the child(ren) to fall and hit the back of their head. Staff members observed the incident and immediately responded to the child(ren). Staff members observed a cut and droplet(s) of blood on the back of the child(ren)'s head. Staff members took the child(ren) inside the classroom to clean the affected area that was bleeding. Once the child(ren) was cleaned up, then staff contacted the child’s authorized representative and notified the representative of the incident. According to reported information, the child(ren) has not returned to the facility since the day of the incident.

Based on information gathered, there appears to be no violations of Title 22 Regulations found at this time.

No deficiencies were cited during this inspection.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Director, Heather Uribe.

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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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