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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364802448
Report Date: 07/26/2022
Date Signed: 07/26/2022 11:36:28 AM


Document Has Been Signed on 07/26/2022 11:36 AM - 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:RIALTO U.S.D. CASEY ELEMENTARY SCHOOLFACILITY NUMBER:
364802448
ADMINISTRATOR:GOOD, KARENFACILITY TYPE:
850
ADDRESS:219 N. EUCALYPTUS AVENUETELEPHONE:
(909) 820-7904
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:24CENSUS: 0DATE:
07/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Emily Dominguez (Principal)TIME COMPLETED:
11:25 AM
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On 07/26/2022 at time listed above Licensing Program Analysts (LPA) Justin Giese conducted an unannounced visit to the facility to follow up on the submission of an Unusual Incident Report (UIR) that was received by the Regional Office on 05/23/2022 and processed on 07/08/2022. LPA met with School Principal, Emily Domingues to discuss the purpose of the visit. There were no children or preschool staff present due to school closing for the summer break. Principal stated the incident occurred close to the end of planned instruction for that school year.

On June 23, 2022 Facility Staff self reported an incident where a child in care sustained an injury on the preschool playground. UIR stated that around 09:35am a child was playing on the climbing structure, they misses a step while climbing to the platform and fell off of the play structure. As a result, the child sustained a broken arm. UIR stated Two facility staff were present and immediately assisted the child after the fall. Paramedics and Child's Parents/Guardians were contacted and Ice was applied to the Child's arm. UIR stated the child was taken by ambulance to the emergency room, it was later determined the child sustained a broken arm from the fall.

Principal stated since the instructional period for the year was approaching the end, the child did not return to the facility after the incident had occurred. At time of this visit, LPA toured the facility playground and examined the play structure. LPA did not observe anything out of the ordinary. Play structure was in sound shape as well as the rubber padding surrounding the play structure. The incident was accidental in nature and there appear to be no violations of Title 22. Facility staff were present and quick to aide the child after the fall. Parents/guardians were notified immediately and the Facility has fulfilled its reporting requirements to Licensing.

An exit interview was conducted, LPA provided the Principal with a copy of this report and a notice of site visit on 07/26/2021. Notice of site visit must be displayed for the next 30 days.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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