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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334812555
Report Date: 03/10/2026
Date Signed: 03/10/2026 02:25:58 PM

Document Has Been Signed on 03/10/2026 02:25 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: 35CENSUS: 20DATE:
03/10/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Lacy HughesTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Sumayya Habeebulla conducted an unannounced annual inspection on 03/10/2026 at 11:55 AM. LPA met with Facility Representative Lacy Hughes, who provided a tour of the center. A tour of both the indoor and outdoor areas of the facility was conducted, and the following observations were noted. During the visit the facility had 35 children enrolled and 20 children present.

The required postings, including the facility license, Emergency Disaster Plan (LIC610), Earthquake Preparedness Checklist (LIC9148), Parent’s Rights Poster (PUB393), Personal Rights (LIC613A), Child Car Seat Law, and menus, were observed to be up to date and appropriately displayed. The facility is operating within the capacity limits as stated on its license.

During the inspection, staff-to-child ratios were observed; the infant classroom had 6 infants with three staff, the toddler classroom had 14 children and four staff. Classrooms contained age and size-appropriate furniture and equipment, free of hazards. Facility Representative Lacy Hughes confirmed that no weapons are present on the premises, and there are no accessible bodies of water. Facility Representative Lacy Hughes confirmed and is aware that any wading pools or similar items must be emptied immediately after use and stored upright. Drinking water is available both indoors and outdoors, pitchers with filtered water and disposable cups.

Medications are stored in an area that is inaccessible to children and located in the director’s office and the infant classroom. Hazardous items, including disinfectants, cleaning solutions, and other dangerous substances, are stored out of children’s reach, while poisons and toxins are securely locked away.

NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Sumayya Habeebulla
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: FSA-MORENO VALLEY CDC
FACILITY NUMBER: 334812555
VISIT DATE: 03/10/2026
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The floors were observed to be clean, safe, and well-maintained. Highchairs and tables have broad-based legs, and trays that lock into place for additional safety. Changing tables are within arm’s reach of a sink, have a minimum one-inch-thick padding, and feature raised sides of at least three inches covered in washable vinyl or plastic. Proper hand washing procedures were observed before and after diapering and feeding.

The bathrooms were found to be clean, safe, and in proper working conditions. The size of the toilets located in the toddler classroom is size appropriate for the use by toddlers. Outdoor play areas are equipped with age and size-appropriate equipment in good condition. The food preparation area is clean, free of litter and pests, and properly maintained. Meals and snacks are not prepared on site. Meals and snacks are pre-prepared and delivered to the facility. Food is stored correctly to prevent contamination. Waste containers have tight-fitting covers and are in good repair.

The sign-in/sign-out records were reviewed and found to be compliant with regulations. Disaster drills are conducted at least every six months, with the most recent drill occurring on 02/27/2026. A review of children’s and staff records confirmed that all required documents are complete. Staff qualifications meet licensing requirements, and at least one staff member has a valid Pediatric CPR/First Aid certification and was present, with certification expiration dates documented. The director has completed Health and Safety Training. Background clearances for all required staff members have been verified, ensuring compliance with criminal records and child abuse index clearance requirements.

The director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871 must obtain a criminal record clearance or exemption or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days, or if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test as specified in Health and Safety Code section 1597.16.

NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Sumayya Habeebulla
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
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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: FSA-MORENO VALLEY CDC
FACILITY NUMBER: 334812555
VISIT DATE: 03/10/2026
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For childcare center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

LPA verified that the lead testing was completed in accordance with the Written Directives (Interim Licensing Standards) outlined in PIN 21-21.1-CCP.

CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES

LPA discussed safe sleep regulations with the Facility Representative and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource . LPA also informed the director of the importance of checking for and removing any recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility provided Incidental Medical Services – IMS. LPA reviewed medication storage of equipment/supplies and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA compliance was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY), and the link to publication: Commonly Asked Questions about Child Care Centers and the ADA" available at https://www.ada.gov/resources/child-care-centers/.

The director was informed about the MyChildCarePlan.org website, a consumer education resource that HELPS families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

LPA reviewed reporting requirements with the director, emphasizing that any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven days in writing. The Duty Officer can be reached Monday through Friday from 8:00 AM to 5:00 PM at (951) 782-4200, or reports may be emailed to UnusualIncidentReportsDO10@dss.ca.gov.

NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Sumayya Habeebulla
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
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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: FSA-MORENO VALLEY CDC
FACILITY NUMBER: 334812555
VISIT DATE: 03/10/2026
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To improve the quality of inspections, and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

The director was requested to update and submit the following documents within 30 days, if applicable:

· LIC 500 Personnel Report,


· LIC 610 Emergency & Disaster Plan,
· Parent Handbook/Program Curriculum/Admission Policies and Procedures/Fee Schedule (if updates have been made or if the file copy is older than two years),
· LIC 309 Administrative Organization (if updated within the past two years), and
· LIC 308 Designation of Administrative Responsibility (if updated within the past two years).

See LIC809-D for cited deficiencies, if applicable.

A Notice of Site Visit was provided and must remain posted for 30 days.

An exit interview was conducted with Facility Representative Lacy Hughes, and a copy of this report was reviewed. Appeal rights were discussed and provided during the exit interview with Facility Representative Lacy Hughes.

NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Sumayya Habeebulla
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2026 02:25 PM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 03/10/2026 at 01:57 PM
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: FSA-MORENO VALLEY CDC
FACILITY NUMBER: 334812555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having Staff #1 and Staff #3 complete their Mandated Reporter training every two weeks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2026
Plan of Correction
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Facility Representative agrees to submit a copy of the mandated reporter certificates to the department by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Carlos Martinez
NAME OF LICENSING PROGRAM MANAGER:
Sumayya Habeebulla
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
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