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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334807214
Report Date: 04/29/2024
Date Signed: 04/29/2024 11:55:45 AM

Document Has Been Signed on 04/29/2024 11:55 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:JAN PETERSON CHILD DAY CARE CENTERFACILITY NUMBER:
334807214
ADMINISTRATOR/
DIRECTOR:		LINDA BEDNARFACILITY TYPE:
850
ADDRESS:26895 BRODIAEA AVENUETELEPHONE:
(951) 601-9200
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 92TOTAL ENROLLED CHILDREN: 85CENSUS: 55DATE:
04/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Victoria DeLaVegaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Sumayya Habeebulla arrived at the facility for the purpose of conducting a case management visit. The Department received an unusual incident report (UIR) dated 04/09/24 from the facility stating a child was left unattended without supervision for a period during operational hours.

LPA conducted interviews with pertaining parties, and it was found that Child 1 (C1) had been left alone inside Room #6 in the restroom stall. Room #6 and Room # 5 were outside in the playground during which time C1 needed to use the restroom. Staff 3 brought the child inside the classroom to use the restroom at which time another parent arrived to pick up their child. Staff 3 assisted the parent with the child and left the classroom forgetting that C1 was still in the restroom. After a few minutes Staff 2 had returned from break and entered Room #5 and heard a child call out for the teacher in Room #6. Room 5 has visual view of Room 6. Staff 2 came into Room 6 and walked the child to the playground and that is when the staff realized the child was left alone in the restroom.

From the information received by interviews with staff, and eyewitness, the facility is being cited for violation of the California Code of Regulations Title 22 Section 101229(a)(1) Responsibility for Providing Care and Supervision



See LIC 809D for deficiencies cited.

An exit interview was conducted with the Facility Assistant Director Ms. Victoria DeLaVega, a Notice of Site Visit posted, and a copy of this report was provided to the facility on this date and time.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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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Document Has Been Signed on 04/29/2024 11:55 AM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 04/29/2024 at 11:38 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: JAN PETERSON CHILD DAY CARE CENTER
FACILITY NUMBER: 334807214

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/30/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary...(1) No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual ...
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The Facility Assistant Director agrees to review Title 22 section with staff and retrain staff on the Responsibility for Providing Care and Supervision. TheAssistant Director will provide a written statement of understanding/compliance to the Department by the due date.
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This requirement was not met as evidenced by: Based on interviews a child was left alone in the restroom without supervision and the staff was not aware of the missing child until another teacher found the child and brought it to their attention.
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Assistant Director will provide LIC 9224 to all parents enrolled for a period of one year and keep a copy in each child's file for review by the Department.

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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:Carlos Martinez
LICENSING EVALUATOR NAME:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024


LIC809 (FAS) - (06/04)
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