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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364815015
Report Date: 01/13/2020
Date Signed: 01/14/2020 05:17:50 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:ARCHIBALD RANCH CHRISTIAN PRESCHOOLFACILITY NUMBER:
364815015
ADMINISTRATOR:LAURA O'BRIENFACILITY TYPE:
850
ADDRESS:13344 S. ARCHIBALD AVENUETELEPHONE:
(909) 947-2722
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY:111CENSUS: 37DATE:
01/13/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:Laura O'BrienTIME COMPLETED:
06:00 PM
NARRATIVE
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On January 13, 2020, Licensing Program Analysts (LPAs) Blanca Ruiz-Silva, John Huynh and Licensing Program Manager (LPM) Aaron Ross arrived at the facility on a Case Management visit to follow-up on an Unusual Incident/Injury ( UIR) Report, LIC 624 for an incident that took place 11/21/19, submitted by the facility on 12/18/19. At the time of visit, LPAs toured the facility took census, and LPA B.Ruiz-Silva met with Laura O’Brien, Director - to discuss the reported incident. During the inspection, LPAs also interviewed Staff and records relevant to the investigation were reviewed and additional documents were obtained. Child involved in incident was not present and not interviewed. However, Information provided on unusual incident, stated that on November 21, 2019, at approximately 09:30 am, Staff reported observing a child running around the classroom. Staff repeatedly redirected the child to sit down, but child continued to run around, climbing chairs and tables, as well as knocking down chairs. Staff approach child who was running away and held his/her hand. Staff stated that the child was wiggling, pulling and squirming. When staff was attempting to direct the child to the carpet, the child resisted by falling to the floor. Staff then heard a pop in his/her arm. Child started crying and he/she was unable to move his/her arm. Therefore, the 1st staff member reported the incident to 2nd staff member. The 2nd staff member informed the Director of the incident. Legal guardian was notified of the incident and he/she arrived to pick up child. Child was taken to the doctor due to this incident and child received medical attention. Child returned to the facility the following date.

Based on interviews conducted and additional document obtained by the facility, the information reported to the Department was verified through interviews with relevant parties. There is a Violations of Title 22 Regulations pertaining to the reported incident.

See LIC809-D for deficiency

An exit interview was conducted with Laura O’Brien, Director. Appeal rights were explained and a copy of this report and LIC 9224 were given to facility representative. A NOTICE OF SITE VISIT WAS ISSUED, and LPA verified that it was POSTED IN A PROMINENT LOCATION before leaving the facility. Director understands that it must remain posted for THE NEXT 30 DAYS.
THIS REPORT MUST BE AVAILABLE TO THE PUBLIC FOR THREE YEARS
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Blanca Ruiz-SilvaTELEPHONE: (951) 233-5594
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2020
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: ARCHIBALD RANCH CHRISTIAN PRESCHOOL
FACILITY NUMBER: 364815015
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2020
Section Cited

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Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
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This requirement was not met as evidenced:
Facility failed to report that Child received medical attention. The incident took place on 11/21/19 however the facility submitted the UIR on 12/18/19. "This poses a potential risk to the Health and Safety of the 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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Blanca Ruiz-SilvaTELEPHONE: (951) 233-5594
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2020
LIC809 (FAS) - (06/04)
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