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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372005410
Report Date: 01/31/2024
Date Signed: 01/31/2024 09:49:53 AM


Document Has Been Signed on 01/31/2024 09:49 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:FALLBROOK CHILD DEV. CENTERFACILITY NUMBER:
372005410
ADMINISTRATOR:JOHNSON, SARINAFACILITY TYPE:
850
ADDRESS:320 N. IOWA ST.TELEPHONE:
(760) 728-5402
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:41CENSUS: 22DATE:
01/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Yvette RojasTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Keely Messerschmidt arrived at the facility on a case management inspection to follow-up on an Unusual Incident Report (UIR) which occurred on January 23rd, 2024 per Director. LPA met with Authorized Representative Yvette Rojas, and provided purpose of inspection. At the time of inspection, LPA toured the facility, took census, interviewed and reviewed documents previously submitted to the department with Ms. Rojas.

The reported incident took place on January 23rd, 2024, regarding Child #1 climbing on blocks while outside where child slipped hitting forehead which required stitches.

Based on interview nothing further is needed. An exit interview was conducted and a copy of this report was provided.

Notice of site visit was provided and must remain posted for 30 days.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 505-6334
LICENSING EVALUATOR NAME: Keely MesserschmidtTELEPHONE: (951) 781-4200
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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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