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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374845129
Report Date: 02/24/2020
Date Signed: 02/24/2020 03:49:02 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:MAAC FOOTHILL DRIVEFACILITY NUMBER:
374845129
ADMINISTRATOR:ANDREOLA,APRILFACILITY TYPE:
850
ADDRESS:1410 FOOTHILL DR.TELEPHONE:
(760) 639-4465
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:20CENSUS: 17DATE:
02/24/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:April AndreolaTIME COMPLETED:
04:00 PM
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LPA Joanne Domingo arrived at the facility on a case management visit to follow-up on an unusual incident report submitted by the facility on 2/13/2020. At the time of visit, LPA toured the facility playground and took pictures of the play structure. LPA took census, and met with Lead Teacher, Yesenia Buelma to discuss the reported incident. Director, April Andreola arrived shortly. During the visit, LPA also spoke with the Teacher who witnessed the incident as it took place.

It was disclosed that during morning outside play on 2/04/2020 at approximately 9:55am, the children were told to start lining up at the gate with Staff #1. Staff #2 was walking the playground and instructing the children who were still playing to go ahead and line up with Staff #1. Child #1 started to run towards the play structure and proceeded to step up onto the first step when Child #1 miscalculated their step, their foot slipped causing Child #1 to fall forward on their face. Child #1 sustained a scrape to their right side temple near the eye. Staff #2 administered first aid and assessed the child for any other injuries. Child #1's parent was called and brought Child #1 to the doctors. Child #1 returned the following day without any restrictions

Based on the information obtained during the visit, as well as an inspection of the play ground and play structure, there appeared to be no violations of Title 22 Regulations pertaining to the reported incident.

An exit interview was held with Director- April Andreola. A Notice of Site visit was issued, along with a copy of this report. This report shall be public record for three years.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Joanne DomingoTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2020
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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