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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364807113
Report Date: 02/08/2022
Date Signed: 02/08/2022 02:13:46 PM

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:SBCUSD-ROBERTS ELEMENTARYFACILITY NUMBER:
364807113
ADMINISTRATOR:KELLY, LATASHIAFACILITY TYPE:
850
ADDRESS:494 E. 9TH STREETTELEPHONE:
(909) 388-6409
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92410
CAPACITY:36CENSUS: 7DATE:
02/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Tyronza SoaresTIME COMPLETED:
02:20 PM
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Licensing Program Analysts (LPAs) Taadhimeka Zeigler and Justin Giese conducted a case management visit to follow up on an unusual incident that occurred on January 26, 2022. LPAs met with teacher, Tyronza Soares, and the facility was toured. LPAs conducted interviews and requested records.

On January 26, 2022, Child #1 was running on the playground and tripped, fell, and hit her head on the playground structure. Staff #1 immediately sent Child #1 to the nurse and first aid was provided. The child’s representative was also notified. The child’s representative took the child to seek medical attention on January 26, 2022, the child required two stitches.

During interviews it was disclosed that Staff #1 witnessed Child #1 running on the playground, Staff #1 advised Child #1 to stop running. Child #1 then fell. Staff #1 was near the child when the incident occurred but could not get to the child in time to prevent the child from falling. Child #1 returned to school the following day, January 27, 2022.

Based on the information obtained during the visit, as well as an inspection of the playground, there appeared to be no violation of Title 22 Regulations pertaining to the reported incident. No deficiencies cited at this time.

Exit interview conducted. Report provided to Tyronza Soares.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Taadhimeka ZeiglerTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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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