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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334807214
Report Date: 08/17/2023
Date Signed: 08/17/2023 01:45:22 PM

Document Has Been Signed on 08/17/2023 01:45 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 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: 92TOTAL ENROLLED CHILDREN: 73CENSUS: 61DATE:
08/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Linda BednarTIME COMPLETED:
01:30 PM
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On today’s date and time stated Licensing Program Analyst (LPA) Sumayya Habeebulla conducted a case management in response to the receipt of an unusual incident report submitted to the department by the facility on 07/29/23. LPA met with director Ms. Linda Bednar to gather additional details surrounding the incident.

The UIR received on 07/29/23 indicated that a Child Protective Service (CPS) report was made on a suspected child abuse. The director stated that during the afternoon diaper change, Child 1(C1) stated “ouch” to Staff 1 (S1) when being wiped. C1 then stated that her dad touched her. As per the director, the child is prone to urinary tract infections and has had multiple cases. Facility wanted to take an extra precaution by reporting to CPS. C1 has not had any days of absence since the incident and is attending the facility regularly. CPS has determined the case does not need any intervention.

An exit interview was conducted, and this report was reviewed with the licensee Linda Bednar. Appeal rights were discussed and provided during the exit interview.

SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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