364807706-1-15-2020-09-CC-GSEA-BL628R-20200124161046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 364807706
Report Date: 01/15/2020
Date Signed: 01/15/2020 10:59:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2020 and conducted by Evaluator Giselle Carbullido

PUBLIC

COMPLAINT CONTROL NUMBER: 09-CC-20200110114350

FACILITY NAME:	RIALTO U.S.D. BEMIS ELEMENTARY SCHOOL		FACILITY NUMBER:	364807706
ADMINISTRATOR:	KRIZEK, PATRICIA		FACILITY TYPE:	850
ADDRESS:	774 E. ETIWANDA AVENUE		TELEPHONE:	(909) 820-7916
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	24	CENSUS: 23	DATE:	01/15/2020
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Karen Good, Director; Suzanne Reyes, Teacher		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility in disrepair- water faucet

INVESTIGATION FINDINGS:

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On 01/15 /20 a complaint inspection was conducted by Licensing Program Analyst (LPA) Giselle Carbullido in response to the receipt of a complaint received on 01/10/20. During today’s visit, LPA toured the facility and census was taken, with 23 children and 3 adults present. LPA met with Suzanne Reyes Teacher and Karen Good, Director.

It was alleged that facility is in disrepair- water faucet. During the investigation, the LPA interviewed staff reviewed records and obtained photos.
Staff interviews reported work orders and monthly reports have been made since January 2019 with no follow up by school maintenance.
During the investigation, the LPA observed and obtained photos of leaking water faucet.
Correspondence documentation reveals efforts by Teacher to have faucet repaired since January 2019.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle Carbullido	TELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 09-CC-20200110114350

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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. BEMIS ELEMENTARY SCHOOL	FACILITY NUMBER: 364807706
	VISIT DATE: 01/15/2020

NARRATIVE

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Based on the information obtained from staff interviews, records, pictures, and the LPA’s own observation, the allegation of facility water fountain being in disrepair was SUBSTANTIATED.

SEE LIC 9099-D for the deficiency cited.

The Director was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, a copy of this report and notice of Site Visit was provided to the Director, and the LPA observed the Notice of Site form was posted by staff. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC FOR THREE YEARS.

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle Carbullido	TELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 09-CC-20200110114350

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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. BEMIS ELEMENTARY SCHOOL	FACILITY NUMBER: 364807706
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/24/2020 Section Cited CCR 101238(a)	1 2 3 4 5 6 7	Buildings and Grounds: 101238(a): The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Director of preschool program will submit proof of repair to LPA Carbullido by POC due date of 01/24/2019.
	8 9 10 11 12 13 14	Based on LPA observation and record review, the facility did not repair a leaking water faucet located in preschool's outside play area. This poses a potential health and safety risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle Carbullido	TELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2020

LIC9099 (FAS) - (06/04)

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