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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334803849
Report Date: 11/07/2022
Date Signed: 11/07/2022 01:10:48 PM

Document Has Been Signed on 11/07/2022 01:10 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:JUSD/VAN BUREN ELEMENTARYFACILITY NUMBER:
334803849
ADMINISTRATOR:KATRINA BROOKSFACILITY TYPE:
850
ADDRESS:9501 JURUPA ROADTELEPHONE:
(951) 222-7850
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 16DATE:
11/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kristy Ulloa (PM Lead Teacher)TIME COMPLETED:
01:20 PM
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On 11/07/2022 at time listed above Licensing Program Analysts (LPA) Justin Giese conducted an unannounced visit to the facility to follow up on the submission of an Unusual Incident Report (UIR) that was received by the Regional Office on 10/26/2022 and processed on 11/01/2022. LPA met with PM Lead Teacher, Kristy Ulloa, to discuss the purpose of the visit.

On October 26, 2022 Facility Staff self-reported an incident where a child in care sustained an injury on the playground. UIR stated that around 01:20pm two children were both trying to go up the stairs on the play structure at the same time. One of the children pushed the other, resulting in one child falling from the second step of the stairs. UIR stated the child that fell was observed to favor their left wrist and complained of pain afterwards. UIR stated the fall was witnessed by facility staff as it had occurred. Staff immediately went to the child, assessed their condition and administered an ice pack.

The parent/guardian of the child was contacted, and the child was picked up shortly after incident. UIR stated the parent/guardian contacted the facility the following day to inform that the child had been seen by a physician and it was determined they sustained two hairline fractures on their left wrist. The child was given a splint for their wrist and cleared to return to the facility on 10/28/2022.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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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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: JUSD/VAN BUREN ELEMENTARY
FACILITY NUMBER: 334803849
VISIT DATE: 11/07/2022
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At time of this visit, LPA toured the facility playground where the incident had occurred. In addition, LPA interviewed the children and staff involved in this incident. While touring the playground and play structure area, LPA was shown by staff where and how the incident occurred. LPA observed a set of 4 floating circular steps that spiral upwards to the top of the play structure. It was stated by staff that the two children were playing a game and running around the playground area together prior to the incident. Staff stated they witnessed the two children attempt to climb the floating steps at the same time. The child fell from the second step as a result of both children trying to occupy the small space consecutively and do not believe the child was intentionally pushed from the step.

LPA interviewed the children involved in this incident. Statements recorded from both children and staff corroborate statements that both children were playing a game, running around the play structure and attempted to climb the steps at the same time. Both children involved stated the incident was an accident. Going forward, staff stated they have been monitoring this area of the play structure more closely to assure only one child at a time occupy the steps. Staff have reminded all the children in care to be mindful of one another and to use the steps/stairs one at a time.

Statements recorded form interviewing all parties involved revealed the fall was not the result of a child being intentionally pushed and injury was accidental in nature. Based on LPA observations and interview there appear to be no violations of Title 22. Facility staff were present and quick to aid the child after the fall. Parent/guardian was notified immediately, and the Facility fulfilled its reporting requirements to Licensing.

An exit interview was conducted, LPA provided the PM Lead Teacher with a copy of this report and a notice of site visit on 11/07/2022.

Notice of site visit must be displayed for the next 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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