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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376625362
Report Date: 05/23/2019
Date Signed: 05/23/2019 02:34:44 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:WILLIAMS, DEVYN FAMILY CHILD CAREFACILITY NUMBER:
376625362
ADMINISTRATOR:DEVYN WILLIAMSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 521-0736
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:14CENSUS: 12DATE:
05/23/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Devyn WilliamsTIME COMPLETED:
02:45 PM
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Licensing Program Analysts, Carlos Martinez and Marlene Wong, arrived to follow up on an unusual incident report that was submitted to Licensing by the facility on 08/06/18. LPAs met with Devyn Williams, Licensee, who allowed LPAs entry into facility.

According to Ms. Williams, Child #1 was in the back yard playing tag with other children, when he tripped over his feet, fell and landed on his right elbow. Ms. Williams said Taylor Steele, Assistant, was in the backyard supervising and witnessed the whole event. She stated she was in the kitchen and only witnessed what happened after the fall. Afterwards, Child #1 was crying and favoring his right arm. Ms. Williams said she called his grandparents who picked up the child around 12:30pm and took him to the hospital (Rady). She said Child #1 had sustained a fracture to his right arm. He stayed home for one week and returned to the facility with a soft cast. Child #1 is currently still attending the day care program.

An exit interview was conducted with Ms. Williams and a copy of this report was provided.

A copy of this report must be made available to the public, at the facility site, for 3 years.

Notice of Site Visit issued.
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Marlene WongTELEPHONE: (951) 248-0229
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019
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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