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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364812756
Report Date: 06/21/2019
Date Signed: 06/21/2019 12:49:23 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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
364812756
ADMINISTRATOR:JENNIFER JOHNSONFACILITY TYPE:
830
ADDRESS:11249 BASELINE AVENUETELEPHONE:
(909) 581-0944
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:40CENSUS: 12DATE:
06/21/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Ashley Rawls/directorTIME COMPLETED:
01:05 PM
NARRATIVE
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Licensing program analyst (LPA) Patricia Berry conducted a case management visit in response to the receipt of an unusual incident report (UIR) from the facility. LPA toured facility and took census. The UIR was received by the licensing agency on 6/12/19. It indicates that a child may have been fed the wrong bottle during feeding time. Facility records were reviewed, and staff interviewed. Closing staff disclosed that end of day 6/12 that child #1 had an extra empty bottle in his bag with child #2's name on it. Staff member noticed that child #2 was missing a bottle from his bag. Assistant director stated opening staff did not recall giving child #1, child #2's bottle; however, child #1's daily sheet indicated that there were 4 bottles fed to child #1 and staff disclosed there was a full bottle in the refrigerator with child #1's name on it making a total of 5 bottles. Staff member stated child #1 only brings 4 bottles each day. LPA observed the bottles are clearly marked with child's name and date. Based on the information gathered, the following violation has been identified: 101223 (a) (2) Each child shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

See LIC809D for cited deficiency of the California Code of Regulations, Title 22, Div. 12.

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

This report must be made available to the public upon request for 3 years.

Acknowledgment of receipt provided to director.

Notice of site visit issued and LPA observed director post the notice.

SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Patricia BerryTELEPHONE: (951) 782-4952
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 364812756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2019
Section Cited
CCR
101223(a)(2)
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Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement was not met as evidenced by Staff fed, an infant in care, the wrong bottle, even though bottles are clearly
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Director immediately notified both parents; sent unusual incident report to CCL 6/12/19. Director started inservice training on 6/21 on feeding practices and procedures. Director stated she will add the health risk of an infant being fed the wrong milk/formula. Agenda and sign in sheet to be submitted by 6/24/19.
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labeled as to whom the bottle belongs to and contents

This is an immediate risk to the health and safety of children in care.
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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: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Patricia BerryTELEPHONE: (951) 782-4952
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
LIC809 (FAS) - (06/04)
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