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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 01:05:31 PM

Document Has Been Signed on 04/15/2024 01:05 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: 23CENSUS: 18DATE:
04/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Sharmalee SamuelTIME VISIT/
INSPECTION COMPLETED:
01:00 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 02/22/2024.

Per the Facility Director, Staff #1 had reported to Child Protective Services (CPS) of an observation made in the classroom. Ms. Samuel stated the CPS representative arrived at the facility and did not provide any document regarding the visit. The CPS worker did visit the family home and the parent was requested to get the child checked at an urgent care for any urinary tract infection. Parent stated to facility Director there were no health issues noted during the visit and they have not heard back from the CPS representative yet. Facility will notify the department of any follow ups from CPS.

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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