334801127-9-29-2022-09-CC-GCAO-CJQMU7-20220929095441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334801127
Report Date: 09/29/2022
Date Signed: 09/29/2022 09:54:48 AM

Document Has Been Signed on 09/29/2022 09:54 AM - 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:	LA PETITE ACADEMY		FACILITY NUMBER:	334801127
ADMINISTRATOR:	KELLIE BARELA		FACILITY TYPE:	850
ADDRESS:	6212 CLAY STREET		TELEPHONE:	(951) 681-3783
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY: 114	TOTAL ENROLLED CHILDREN: 114	CENSUS: 46	DATE:	09/29/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kellie Barela		TIME COMPLETED:	09:15 AM

NARRATIVE

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On 09/29/22 at 8:30 AM, 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 09/22/22. It indicates that a parent found a child unsupervised on the playground and notified the facility staff.

Facility records (UIR self report) were reviewed, and interviews were conducted with the Director and Teacher. Interviews conducted reported a child was left outside on the playground for 30 minutes. Based on the information gathered, the following violations have been identified:

CCR 101229(a)(1)
Responsibility for Providing Care and Supervision (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

See LIC809D for cited deficiency of the California Code of Regulations, Title 22, Division 12. An immediate $500.00 civil penalty has been assessed.

An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to facility staff.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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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Document Has Been Signed on 09/29/2022 09:54 AM - It Cannot Be Edited

Created By: Giselle Carbullido On 09/29/2022 at 08:53 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: LA PETITE ACADEMY	FACILITY NUMBER: 334801127
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/30/2022 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	101229(a)(1) Responsibility for Providing Care and Supervision (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility Director agrees to provide this report, cited deficiency issued by the department to the parent(s) of children in care within 24 hours or the next time in care; this includes all newly enrolled children over the next 12 months. Facility Director agrees to submit proof of the signed acknowledgment(s) (LIC9224) to the department by Septemeber 30, 2022.
	8 9 10 11 12 13 14	Based on LPA interviews conducted and Directors acknowledgement and self report, the facility did not maintain supervision of all children which resulted in a child being left unsupervised on the playground This is an immediate risk to the health and safety of children in care.	8 9 10 11 12 13 14	Director also agrees to provide in-service training to staff regarding Responsibility for Providing Care and Supervision and will submit proof of training to the Department by the close of business day 09/30/22 . AN IMMEDIATE CIVIL PENALTY HAS BEEN ASSESSED FOR $500.00.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Gilbert Sena

LICENSING EVALUATOR NAME:

Giselle Carbullido

LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: LA PETITE ACADEMY	FACILITY NUMBER: 334801127
	VISIT DATE: 09/29/2022

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LPA Carbullido informed Director, Kellie Barela that this report dated 09/29/2022 document(s) (1 )Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Carbullido ) informed the Director Kellie Barela to provide a copy of this licensing report dated 09/29/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC809 (FAS) - (06/04)

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