364830600-8-3-2022-09-CC-JGIE-CGXP4F-20220803105905

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364830600
Report Date: 08/03/2022
Date Signed: 08/03/2022 10:59:12 AM

Document Has Been Signed on 08/03/2022 10:59 AM - 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:	VOLUNTEERS OF AMERICA		FACILITY NUMBER:	364830600
ADMINISTRATOR:	FAVIOLA CASTILLO		FACILITY TYPE:	850
ADDRESS:	304 N. PEPPER AVENUE		TELEPHONE:	(909) 562-0901
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	190	CENSUS: 48	DATE:	08/03/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:18 AM
MET WITH:	Naveen Armendarez		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/03/2022 at time listed above Licensing Program Analysts (LPA) Justin Giese conducted an unannounced visit to the facility to follow up on the submission of an Unusual Incident Report (UIR) that was received by the Regional Office on 07/27/2022. LPA met with Director, Naveen Armendarez to discuss the purpose of the visit. LPA took census, reviewed records, toured the facility and conducted interviews. On July 22, 2022 Facility staff self reported an incident that occurred at the facility on July 21, 2022. UIR stated that around 09:54am a child was playing tag with other children and was observed running and chasing other children near the outdoor playground's play structure. While playing with others, the Child lost their balance and fell landing on both of their knees on the padded surface which surrounds the play structure. It was reported that two staff members were present at time of incident. UIR stated facility staff immediately rushed to the Child's aide, assisting them with standing and walking off the playground for further assessment and first aide in a nearby classroom. UIR stated the child was unable to walk and needed the assistance of staff. UIR stated the child pointed to their right knee and stated it was "Hurt". Facility staff immediately contacted the Child's parent/guardian and applied ice to the affected knee while they waited for parent/guardian to arrive and pick up the child. UIR stated the incident was captured on video camera. Facility would follow up with their IT department to retrieve the video of incident occurrence. At time of visit LPA reviewed facility records. LPA was provided an "Ouch Report" which supports the information stated in the UIR. Additionally LPA was provided with a medical assessment for the child from their health care professional, dated 07/21/2022. The assessment stated the child sustained a "closed displaced spiral fracture of shaft of right femur" as a result from the fall.

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin Giese	TELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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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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: VOLUNTEERS OF AMERICA	FACILITY NUMBER: 364830600
	VISIT DATE: 08/03/2022

NARRATIVE

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LPA toured the outdoor playground and area and was shown by staff where the incident had occurred. It was stated the incident occurred near the play structure. LPA observed the outdoor play area's fall/cushioning surface surrounding the play structure to be rubber matting, which was in visibly good condition and free from physical defects.

Director stated the incident was captured on video camera and the saved footage was reviewed by the child's parents/guardians at a later date. LPA was able to review the video footage of the incident at time of visit. LPA was able to corroborate what was reported in the UIR and observed the Child running about and chasing other children near the play structure. The child loses their balance while running and falls to their knees, landing on the rubber padded surface which surrounds the play structure. LPA observed teaching staff present and near the child when the incident took place.

The Child was observed falling to their knees as a result of losing their balance while running/chasing other children. The Child was not observed to be pushed or trip on any obstructions or objects. The incident was accidental in nature and there appear to be no violations of Title 22. Facility staff were present and quick to aide the child after the fall. Parents/guardians were notified immediately and the Facility has fulfilled its reporting requirements to Licensing.

An exit interview was conducted, LPA provided the Director with a copy of this report and a notice of site visit on 08/03/2022.

Notice of site visit must be displayed for the next 30 days.

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin Giese	TELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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