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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543808213
Report Date: 06/13/2019
Date Signed: 06/13/2019 10:33:28 AM

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:PORTERVILLE ED. COMPLEX CDCFACILITY NUMBER:
543808213
ADMINISTRATOR:BENTON, ANGELAFACILITY TYPE:
850
ADDRESS:914 PIONEER AVENUETELEPHONE:
(559) 783-9490
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:46CENSUS: 31DATE:
06/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lorena Lopez, Assistant Site SupervisorTIME COMPLETED:
10:45 AM
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A case management inspection was conducted today by Licensing Program Analyst, Pete Espinoza. LPA met with, Lorena Lopez, Assistant Site Supervisor, to discuss incident which occurred on 05/09/2019. A complete file review was conducted prior to visit. LPA toured facility inside and outside. Census was taken. LPA interviewed staff and observed area in which incident occurred.
Staff stated they were outside with approximately 14 children/3 staff when two of the children had to go to the restroom. Staff stated they escorted the two children to the restroom in the classroom. Staff stated the janitor had just finished mopping the restroom when children entered. Staff stated there were no mats on floor when children entered the restroom. Staff stated when one Child went from one toilet to another toilet, she observed the Child slip and fall, hitting his mouth on the toilet. Staff stated when they picked up the Child, they observed bleeding from the mouth. Staff stated they cleaned the wound and applied an ice pack. Staff stated they called Mom on phone and she told them babysitter will pick up child. Staff stated babysitter arrived to pick up Child a short time later. Staff stated later in the day, Mom came to center to tell them she took Child to dentist. Staff stated they discussed incident with Mom and she provided a note from dentist indicating a follow-up appointment. Staff stated child returned to facility the following day. Staff stated since the incident, janitor has changed his routine to clean and mop children’s restroom early before children arrive.
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.
Staff provided copies of Agency Accident Report Form, First Aid Notification to Parents Progress Notes and follow-up appointment notice from dentist.

Per California Code of Regulations Title 22, Division 12, no deficiency cited during today's visit. Exit interview conducted with the Lorena Lopez, Assistant Site Supervisor.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Peter EspinozaTELEPHONE: 661-644-8231
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
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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