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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911138
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:33:15 PM

Document Has Been Signed on 04/18/2024 02:33 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:IMMANUEL LUTHERAN PRESCHOOLFACILITY NUMBER:
330911138
ADMINISTRATOR/
DIRECTOR:		TRONA SALGADOFACILITY TYPE:
850
ADDRESS:5455 ALESSANDRO BLVD.TELEPHONE:
(951) 682-4211
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 87TOTAL ENROLLED CHILDREN: 87CENSUS: 53DATE:
04/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:41 PM
MET WITH:Angela Knapp, SupervisorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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A case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 04/11/2024. It indicates a child sustained an injury while playing on outdoor play equipment.
Facility records were reviewed, and pertinent parties’ interviews were conducted, including staff, and authorized representatives. LPA toured outdoor activity area and play equipment and did not observe any hazards present. Based on information gathered, the facility acted appropriately, and no violations have been identified. Facility provided comfort, 1-1 assistance to the child and notified authorized representatives, and implemented medical accommodations provided by authorized representatives. Facility completed reporting requirements as required by CCR regulations for Reporting Requirements-(submission of LIC624) to the California Department of Social Services. Facility maintained staff to child ratios for supervision and communication with authorized representatives.
An exit interview was conducted, and a copy of this report, appeal rights and notice of site visit were provided to facility staff, Angela Knapp, Supervisor.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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