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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334807214
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:49:23 AM


Document Has Been Signed on 08/04/2022 11:49 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:LINDA BEDNARFACILITY TYPE:
850
ADDRESS:26895 BRODIAEA AVENUETELEPHONE:
(951) 601-9200
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:92CENSUS: 54DATE:
08/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Linda BednarTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sumayya Habeebulla arrived at the facility to conduct a visit for a different purpose, however, during the visit on 07/23/22, LPA observed a video footage of an incident where a staff in Room 5 placed her legs on a child during nap time.

Interviews with staff and children and video footage revealed that the staff places her legs on the back of the child during nap time in order to make him stay on the cot. Video footage showed the staff presses her leg on the child’s shoulder and neck area and her right leg on the child’s legs (back of the knee area). The footage also reveals the child squirming at times. Interviews with staff and children also revealed this is not a sole incident and has been happening for a while with everyone’s knowledge.

Based on the information obtained through interviews and video footage it has been determined that Personal Rights of children in care have been violated at the facility.

See LIC 809D for deficiencies.



Appeal rights were discussed and provided during the exit interview.

An Exit Interview was conducted, A Notice of Site visit was given, and the Licensee understands that it must remain posted for 30 days

SUPERVISOR'S NAME: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya HabeebullaTELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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 08/04/2022 11:49 AM - It Cannot Be Edited

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 STREET, STE 700
RIVERSIDE, CA 92501


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2022
Section Cited

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(a) The licensee shall ensure that each child is accorded the following personal rights:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule....physical functioning.

Based on interviews and video footage...
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... A Staff in Room 5 (Puffer Fish) has been witnessed in using inappropriate language when communicating with children in care and of Physically holding a child down on the cot using her thighs which poses an immediate personal rights risk to children in care.
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 The statement will also include the names and signatures of all staff who attended the training.

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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 MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya HabeebullaTELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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