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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503604250
Report Date: 10/26/2021
Date Signed: 10/26/2021 01:39:56 PM

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:ALBERTA MARTONE PREFORMAL CENTERFACILITY NUMBER:
503604250
ADMINISTRATOR:NUNES, HEIDIFACILITY TYPE:
850
ADDRESS:1413 POUST ROADTELEPHONE:
(209) 574-8172
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:24CENSUS: 9DATE:
10/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kimbra DraperTIME COMPLETED:
01:50 PM
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On October 26, 2021, Licensing Program Analysts (LPA) Kari McWilliams conducted an unannounced case management inspection. LPA toured the facility and a census was taken. LPA met with coordinator Kimbra Draper. The purpose today's inspection was to discuss an incident that occurred on September 2, 2021. During today's inspection LPA McWilliams interviewed staff, review children files, and inspect facility grounds. A complete file review was conducted prior to today's inspection.

An Unusual Incident Report was submitted to the Fresno Community Care Licensing Office regarding an incident that occurred on September 2, 2021 where Child #1 was playing on the structure and slipped off of the second step of the play structure falling landing with their arm behind their back. Child #1 was transported to urgent care by mom where ex-rays were taken and determined that child #1 broke their arm above the elbow and required surgery.

Through staff interviews, facility inspection of the play structure and observations it is determined that the structure has adequate tanbark cushioning under the step and child #1 falling and breaking his arm was not due to lack of supervision or care of staff present.

Per Title 22 Division 12 Chapter 1 of the California Regulations, there are no deficiencies being cited. An exit interview was conducted with Coordinator Draper.



A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7980
LICENSING EVALUATOR NAME: Kari McWilliamsTELEPHONE: (559) 341-4724
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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