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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500319966
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:12:41 AM


Document Has Been Signed on 05/24/2022 11:12 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:DON PEDRO STATE PRESCHOOLFACILITY NUMBER:
500319966
ADMINISTRATOR:GONZALES, MARYFACILITY TYPE:
850
ADDRESS:2300 DON PEDRO ROADTELEPHONE:
(209) 556-1545
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY:72CENSUS: 31DATE:
05/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Christine Cardosa TIME COMPLETED:
11:20 AM
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On 05/24/2022, Licensing Program Analysts (LPAs) Jeovanna Yanez and Ka Vang conducted an unannounced case management inspection. LPAs toured the facility and a census was taken. LPAs met with Assistant Preschool Director (APD), Christine Cardosa. The purpose today's inspection was to discuss an incident that occurred on 5/10/22, in which child #1 received a head injury. This incident was reported to the Fresno Community Care Licensing Office on 5/10/22 by APD, Christine Cardosa.


APD stated on 05/10/2022, there were twelve (12) children and four (4) staff present during circle time, when Child #1 got up and climbed on top of the playhouse area, then onto a counter and fell backwards and hit his head on the corner of a wooden play stove. Staff #1 had previously talked with the child to not climb up and attempted to get child down from the counter before he fell off. Child #1 then got up and ran to another area in the classroom, where he started to bang his head on the floor until he started to bleed. Staff #1 checked on the child and confirmed he had a gash on the back of his head. APD reported Staff #1 assisted the child and provided first aide while parent was called. Parent arrived shortly after and took child to the ER, where Child #1 received 3 staples on the back of his head. Child returned to the facility on 5/18/22 and is reportedly doing fine.

LPA reviewed pertinent documentation at the facility. LPA verified teacher-child ratios were being followed during time of incident. Based on the information obtained, this appears to be an isolated incident and Staff took appropriate measures to address the child's injury, following proper policies and procedures and no regulations were violated.

Per California Code of Regulations Title 22, Division 12, no deficiency cited during today's visit. Exit interview conducted with the Assistant Preschool Director, Christine Cardosa.
LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Jeovanna YanezTELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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