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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364841081
Report Date: 10/25/2019
Date Signed: 10/25/2019 02:05:19 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:ABUNDANT PRESCHOOL OF LEARNINGFACILITY NUMBER:
364841081
ADMINISTRATOR:DOMINIGUE LUCIENFACILITY TYPE:
850
ADDRESS:10900 CIVIC CENTER DRIVETELEPHONE:
(909) 204-4514
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:128CENSUS: 93DATE:
10/25/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Dominque Lucien/DirectorTIME COMPLETED:
02:20 PM
NARRATIVE
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A case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 10/10/19. It indicates a child fractured arm while outside playing on structure.

Facility records were reviewed and staff were interviewed. Based on the information gathered, the following violation has been identified: Staff stated the children were playing on the play structure and they did not see the incident occur. Staff stated they were folding a tent on the playground due to the wind, leaving their backs turned from the play structure. LPA reviewed video footage of the incident and staff were not observing children on the play structure, resulting in a child falling from structure and fracturing arm. Director reported the incident immediately to CCL 10/10/19.

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 director.

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

Acknowledgement of receipt provided.

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Patricia BerryTELEPHONE: (951) 782-4952
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019
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: ABUNDANT PRESCHOOL OF LEARNING
FACILITY NUMBER: 364841081
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2019
Section Cited

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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This requirement was not met as evidenced by staff were not observing children on the play structure, resulting in a child falling from the structure and fracturing arm.

This is an immediate risk to the health and safety if 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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Patricia BerryTELEPHONE: (951) 782-4952
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2019
LIC809 (FAS) - (06/04)
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