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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334812555
Report Date: 04/15/2024
Date Signed: 04/15/2024 01:04:40 PM

Document Has Been Signed on 04/15/2024 01:04 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:FSA-MORENO VALLEY CDCFACILITY NUMBER:
334812555
ADMINISTRATOR/
DIRECTOR:		SHARMALEE SAMUELFACILITY TYPE:
830
ADDRESS:21250 BOX SPRINGS RD #115TELEPHONE:
(951) 779-9784
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 18DATE:
04/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Sharmalee SamuelTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs), Sumayya Habeebulla and Kelli Waters conducted a case management visit at the facility. Facility Director, Ms. Sharmalee Samuel had submitted an Unusual Incident Report on 03/19/2024. Per the report Parent of Child #1 (C1) and child #2 (C2) reported to the facility that the children have confirmed cases of Hand, Foot, and Mouth. Ms. Samuel stated that the facility conducted deep cleaning and the parents of enrolled children were notified via email and Class Dojo. All children were observed for symptoms and strict hand washing and hygiene procedures were followed. C1 & C2 returned to the facility on 03/21/24 once they were clear of all symptoms.

An exit interview was conducted, and this report was reviewed with the facility representative Ms. Sharmalee Samuel. Appeal rights were discussed and provided during the exit interview.

SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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