198003094-1-20-2023-33-CC-CTUA-CN9RVD-20230120122122

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198003094
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:21:34 PM

Document Has Been Signed on 01/20/2023 12:21 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:	KINDERCARE LEARNING CENTER		FACILITY NUMBER:	198003094
ADMINISTRATOR:	NATILEE CARTER		FACILITY TYPE:	850
ADDRESS:	455 E. FOOTHILL BOULEVARD		TELEPHONE:	(909) 599-0597
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	96	CENSUS: 47	DATE:	01/20/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lauren Mier and Roxanne Gonzales		TIME COMPLETED:	12:00 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 January 20, 2023, at 10:00 am Licensing Program Analyst, (LPA) Carolyn Tuba conducted an unannounced inspection to follow-up on an ongoing complaint investigation. A Covid-19 risk assessment was conducted prior to entering the facility. LPA was guided on a tour of the facility at 10:15 am where there was a census of 47 children and 5 staff in care. The Director, Roxanne Gonzales arrived approximately around 11:15 am. and LPA identified herself. Brief Summary of incident: On 12/22/2022 at 10:00 am, during outside time on the playground, Child #1 (C1) was playing on the slide and went down head first and hit her chin on a rock, causing her to split her chin open. Child cried and teacher placed pressure and cleaned her chin up. Mother works at the facility in the Infant room and took C1 for medical attention, which required child needing 5 stitches. After investigating further with office support staff and there was a call placed by the facility stating that they were having issues faxing the Unusual Incident Report (UIR) to the department's fax number. The Assistant Director provided LPA a copy of the email sent to LPA, Jennifer Hua dated December 22, 2022, and LPA provided the Assistant Director during the initial visit of 12/28/2022 and provided the Director with the email of MPROincidentreports@dss.ca.gov to send UIRs in the future. This means that the facility meets the following regulation 101212(d)(1), 101212(d)(2) and 101212(1)(B). 101212 Reporting Requirements Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Carolyn Tuba	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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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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: KINDERCARE LEARNING CENTER	FACILITY NUMBER: 198003094
	VISIT DATE: 01/20/2023

NARRATIVE

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(1) Events reported shall include the following:

(B) Any injury to any child that requires medical treatment.

No citations have been issued at this time.

The Notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative, a civil penalty of $100 can be assessed.

Exit Interview was conducted and appeal rights (LIC 9058 03/22) were given, along with a copy of this report was provided to the Director, Roxanne Gonzales.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Carolyn Tuba	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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