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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364806732
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:31:11 PM


Document Has Been Signed on 02/23/2022 03:31 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/CRAM SCHOOL AGE SITEFACILITY NUMBER:
364806732
ADMINISTRATOR:VARGAS, JANETTEFACILITY TYPE:
840
ADDRESS:29700 WATER STREETTELEPHONE:
(909) 735-1588
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:95CENSUS: 30DATE:
02/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Naomi WoodardTIME COMPLETED:
03:50 PM
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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 01/24/2022. It indicates that on 01/21/2022 child #1 tilted the bench and it flipped over and landed on his hand. Two staff were present at the time of the incident.

Facility records were reviewed and staff and child #1 were interviewed. Based on information gathered, the facility acted appropriately and no violations have been identified. Staff immediately stopped the child's finger from bleeding and then called 911 and the child's parent. The incident happened on Friday, 01/21/2022. Child #1 returned to school on the following Monday, 01/24/2022.

On Monday, 01/24/2022, staff talked to the children about safety precautions and the importance of using items in which they were intended to be used. Staff will continue to monitor children as required.

An exit interview was conducted and a copy of this report was provided to facility staff.

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Taadhimeka ZeiglerTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
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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