<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334802965
Report Date: 10/27/2022
Date Signed: 10/27/2022 11:30:49 AM

Document Has Been Signed on 10/27/2022 11:30 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:UC RIVERSIDE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
334802965
ADMINISTRATOR:KIMBERLY PIXLEYFACILITY TYPE:
830
ADDRESS:3333 WATKINS DRIVETELEPHONE:
(951) 827-3854
CITY:RIVERSIDESTATE: CAZIP CODE:
92507
CAPACITY: 54TOTAL ENROLLED CHILDREN: 54CENSUS: 23DATE:
10/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:KImberly PixleyTIME COMPLETED:
09:30 AM
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 the date and time listed above, 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 10/21/22. It indicates a child sustained an injury to the wrist while playing on a play structure.

According to staff interviews conducted, there were 9 children present with 3 staff. Staff interview reported that teacher was standing directly at the side corner of play structure where child fell but was unable to intercept fall. Staff provided first aid (cold compress) and notification to parent.

Parent interview noted child explained they fell and hurt their arm. Parent updated facility on medical status and future appointments. Parent stated they received an incident report from facility.



On 10/27/22 at 9:12AM, LPAs toured and obtained photo of the outdoor activity area where incident happened. LPAs did not observe any hazards on the ground and play structure is on top of rubber foam matting that absorbs a fall.

Based on information gathered from interviews and records, the facility acted appropriately, and no violations have been identified. Facility completed reporting requirements as required by CCR regulations for Unusual Incident Reports (submission of LIC624) to the California Department of Social Services. Facility maintained staff to children ratios for supervision (3 staff to 9 children); outdoor surfaces were free from debris and hazards and maintained communication with parent.

An exit interview was conducted, and LPAs Carbullido and Caywood provided the Director with a copy of this report, appeal rights and notice of site visit during today’s visit.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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 1