364840979-3-11-2020-09-CC-BRSA-BMLTLW-20200311145013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364840979
Report Date: 03/11/2020
Date Signed: 03/11/2020 02:50:22 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 SCHOOL		FACILITY NUMBER:	364840979
ADMINISTRATOR:	MOLINA, CARA		FACILITY TYPE:	850
ADDRESS:	1845 S SULTANA AVENUE		TELEPHONE:	(909) 459-1215
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91761
CAPACITY:	24	CENSUS: 22	DATE:	03/11/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Adriana Melgoza		TIME COMPLETED:	03:05 PM

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 March 11, 2020 at 08:45 a.m., Licensing Program Analysts (LPAs) Blanca Ruiz-Silva and Destinee Hogue arrived at the facility on a Case Management inspection to follow-up on an Unusual Incident Report ( UIR) submitted to the Department. The incident occurred on 03/06/2020 and a written report was submitted by the facility on 03/09/2020. During this inspection, LPAs toured the inside and outside of the facility (specifically were the reported incident took place), took census and captured pictures of the outdoor play area. LPAs met with Director Brenda Mason and Site Supervisor, Adriana Melgoza and discussed the following: Written UIR submitted to the department, documents an incident involving a child who was playing on the playground and stayed on the playground while the class went inside. Interviews were conducted with relevant parties and facility records were reviewed. The investigation process revealed that the child was forgotten outside the playground while children were transitioning from the outside playground to the inside classroom. Per information received during the investigation, the transition period took approximately 15-20 minutes. When staff went outside to look for the child, witness stated that the child was outside the classroom door, and child did not express to be scare or harm. Child was assess by staff and child was integrated to the regular class activity. Parents of the child involved are aware of the incident. Staff admitted that they did not understand how or at what point the child was able to stay behind in the playground without being noticed by anyone for approximately 5 minutes. Although multiple staff were present during the day of the incident, staff failed to adequately met the child's needs by providing care and supervision. Based on all the information obtained from pertinent parties, records review and observations conducted during inspection, there is a violation of Title 22 regulation, pertaining to the reported incident. SEE LIC 809D for the deficiencies cited

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva	TELEPHONE: (951) 233-5594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2020

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: OMSD/SULTANA ELEMENTARY SCHOOL	FACILITY NUMBER: 364840979
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/12/2020 Section Cited	1 2 3 4 5 6 7	101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Staff admissions state the facility failed to provide adequate supervision for a child(ren) in care. Staff admitted that they did not understand how a child was left on the playground and did not know the timeframe the child was left alone (approximately three to five minutes). This is an immediate Health and Safety risk for the children in care.	8 9 10 11 12 13 14	Please contact CCL by 03/12/20 to provide training date. This is a repeat violation within the last 12 months.
	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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva	TELEPHONE: (951) 233-5594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2020

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: OMSD/SULTANA ELEMENTARY SCHOOL	FACILITY NUMBER: 364840979
	VISIT DATE: 03/11/2020

NARRATIVE

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An exit interview was conducted with Director, Brenda Manson and Site Supervisor Adriana Melgoza. 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 ALONG WITH A COPY OF ALL TYPE A DEFICIENCIES (LIC809D) CITED DURING THIS INSPECTION.
A COPY OF ALL TYPE A DEFICIENCIES CITED DURING THIS INSPECTION MUST ALSO BE IMMEDIATELY (within 24 hours of the child’s next day in care) GIVEN TO THE PARENTS OF ALL CHILDREN ENROLLED IN THE CHILD CARE FACILITY AND ANY CHILDREN ENROLLED within the next 12 months.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva	TELEPHONE: (951) 233-5594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2020

LIC809 (FAS) - (06/04)

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