191501775-9-21-2023-33-CC-CTUA-CVVR7C-20230921124607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191501775
Report Date: 09/21/2023
Date Signed: 09/21/2023 12:47:14 PM

Document Has Been Signed on 09/21/2023 12:47 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	CLAREMONT UNITED CHURCH OF CHRIST ECC		FACILITY NUMBER:	191501775
ADMINISTRATOR:	KNIGHT, KRISTY		FACILITY TYPE:	850
ADDRESS:	233 W HARRISON AVE		TELEPHONE:	(909) 624-2916
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 64	TOTAL ENROLLED CHILDREN: 65	CENSUS: 54	DATE:	09/21/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kristy Knight		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/21/2023 an unannounced Case Management-Incident inspection was conducted by Licensing Program Analyst, (LPA) Carolyn Tuba who was following-up on an Unusual Incident Report. Covid risk assessment was conducted and LPA wore appropriate gear. LPA met with Director, Kristy Knight. Director guided LPA on a tour of the facility and took a census of 54 children with 11 staff. The incident occurred on 09/15/2023 and was reported to the Department on 09/18/2023 via a written report emailed to Community Care Licensing Department. The facility reported the incident in a timely manner. LPA interviewed Director, Staff #1 (S1) and #2 (S2). LPA took photos of the area where the incident occurred. Based off interviews the incident occurred at approximately 9:55 am. The Unusual Incident reported that Child #1 (C1) was running on the playground and tripped and fell and hit their head on the cement. It also stated that EMTs were called due to child losing consciousness for a few seconds. LPA interviewed Director, S1 and S2. S2 observed C1 was running with another child and that they tripped and fell. S2 confirmed that C1 was not pushed or tripped over any objects. Based on S1 and S2 interviews they stated that after C1 fell, they were crying and began hyperventilating from the crying and seemed to go limp and lose consciousness for a few seconds. So S2 rubbed C1’s chest and was asking if they were alright. At no time did C1 stop breathing so CPR was not needed. S1 called EMTs while another staff called for the Director and parents of C1. The other staff took the rest of the children present on the playground into their classroom before EMTs arrived. EMTs arrived on the scene 5 to 10 minutes after the incident and at the same time parents arrived, who happen to be near-by. Parent of C1 rode in the ambulance. EMTs took C1’s Page 1 of 2

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CLAREMONT UNITED CHURCH OF CHRIST ECC	FACILITY NUMBER: 191501775
	VISIT DATE: 09/21/2023

NARRATIVE

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vitals and took C1 to the hospital for observation and C1 was released a few hours later. C1 is doing fine and returned to school on 9/18/2023, according to Director, and S1. LPA was unable to interview C1 as they were not at school during this visit and due to C1’s age, they are not verbal enough. Director provided LPA with documentation of the incident report and medical report of C1.

Based on LPA’s observations and interviews, the staff took the proper procedures and C1’s fall was accidental due to running and playing.

No citations are being issued at this time.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director, Kristy Knight.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2