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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374845478
Report Date: 12/20/2019
Date Signed: 12/20/2019 01:22:04 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:ADAMS FAMILY CHILD CAREFACILITY NUMBER:
374845478
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
12/20/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Lynnett AdamsTIME COMPLETED:
01:31 PM
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Licensing Program Analyst (LPA), Otsanya Cameron arrived at the facility to conduct a Case Management visit in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 12/13/19. It indicates that on 12/13/19 a child was bit by a dog living in the child care home. Child #1 sustained a cut on left eyebrow.

Based on information gathered, the facility acted appropriately and no violations have been identified. The Licensee gave first aid to child #1, notified the parent in a timely manner, took measures to ensure the safety of children by immediately separating the dog from the children.
Due to the nature of the injury, the Humane Society was contacted and a Quarantine order was served for the pet dog. Facility provided copies of the report from the Humane Society that was issued on 12/14/2019. A follow up visit from the Humane society is scheduled on 12/23/2019 and licensee will provide the department with any updates.

In addition, the facility has imposed a new protocol to keep the pet in a bedroom or off the property during business hours.

No deficiencies cited, facility is in compliance per the California Code of Regulations Title 22, Division 12.

An exit interview was conducted and a copy of this report was provided to the Licensee.
A copy of this report must be made available to the public upon request for three years
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Otsanya CameronTELEPHONE: (951) 970-1388
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
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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