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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700122
Report Date: 10/29/2021
Date Signed: 11/18/2021 01:02:02 PM

Document Has Been Signed on 11/18/2021 01:02 PM - It Cannot Be Edited

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:CHILDREN'S PARADISE-SHADOWRIDGEFACILITY NUMBER:
376700122
ADMINISTRATOR:CHRISTINA JENKINSFACILITY TYPE:
850
ADDRESS:145 N, MELROSE DR. STE 100TELEPHONE:
(760) 724-5600
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 126TOTAL ENROLLED CHILDREN: 99CENSUS: 21DATE:
10/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:40 AM
MET WITH:Assistant Director/Leanne SparksTIME COMPLETED:
07:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) James Wilkerson conducted a site visit on this date, There was an incident that occurred on 07/08/21 where a child had fallen on his/her back and received an injury and the facility was notified that this required medical attention. This incident was reported to Community Care Licensing as required by Title 22 Regulations.

There are no citations issued for this incident.

An exit interview was conducted, A Notice of Site Visit was posted and a copy of this report was emailed to Keely Messerschmidt on this on this date.

This is an amended report from the original report dated 10/29/21.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: James Wilkerson
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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Document Has Been Signed on 11/18/2021 01:06 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/18/2021 01:03 PM


Created By: James Wilkerson On 10/29/2021 at 06:58 AM
Link to Parent Document Below:
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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHILDREN'S PARADISE-SHADOWRIDGE
FACILITY NUMBER: 376700122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2021
Section Cited
CCR
101212(d)(1)

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Reporting Requirements:

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There is no citation for this date as the incident report was received by this regional office on 07/12/21.
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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:Carlos Martinez
LICENSING EVALUATOR NAME:James Wilkerson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2021


LIC809 (FAS) - (06/04)
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