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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364840979
Report Date: 05/08/2019
Date Signed: 05/08/2019 03:35:08 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:OMSD/SULTANA ELEMENTARY SCHOOLFACILITY NUMBER:
364840979
ADMINISTRATOR:MOLINA, CARAFACILITY TYPE:
850
ADDRESS:1845 S SULTANA AVENUETELEPHONE:
(909) 459-1215
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY:24CENSUS: 24DATE:
05/08/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Brenda MasonTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Nelson Zuniga arrived at the facility to follow-up on an Unusual Incident Report that was submitted on 04/16/2019. incident date of 3/22/2019. The report stated that there was a possible lack of supervision and personal rights violations.

A toured of the facility was taken, facility records reviewed, and interviews were conducted by LPA Zuniga.


Based on the information obtained during the inspections and interviews, there appeared to be no violation of Title 22 Regulations pertaining to the reported incident.


An exit interview was conducted and a copy of this report was reviewed and provided.
Notice of Site Visit issued.
A copy of this report must be made available to the public for 3 years.
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Nelson ZunigaTELEPHONE: (951) 782-6634
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
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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