<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334818112
Report Date: 07/16/2021
Date Signed: 07/16/2021 02:37:46 PM

Document Has Been Signed on 07/16/2021 02:37 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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SIERRA PRESCHOOLFACILITY NUMBER:
334818112
ADMINISTRATOR:MARLIE SEGURA-WILLIAMSFACILITY TYPE:
850
ADDRESS:11077 WHITFORDTELEPHONE:
(951) 689-9492
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 53TOTAL ENROLLED CHILDREN: 0CENSUS: 27DATE:
07/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Marlie Segura WilliamsTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/16/21 at 2:15pm, a case management visit was completed by Licensing Program Analyst (LPA) Giselle Carbullido due to deficiencies found during the course of another inspection.

1) Reporting Requirements: Facility did not report to Community Care Licensing an unusual incident that occurred on 06/03/2021 by telephone or fax to the department by the next business day (24 hours).

SEE LIC 809-D for the deficiency cited.

The Director was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, a copy of this report and Notice of Site Visit was provided to the Director; LPA observed the Notice of Site Visit form was posted by staff. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC UPON REQUEST FOR THREE YEARS.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/16/2021 02:37 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 07/16/2021 at 02:04 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SIERRA PRESCHOOL
FACILITY NUMBER: 334818112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2021
Section Cited
CCR
101212(d)

1
2
3
4
5
6
7
101212(d) Reporting requirements-(d) ...during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Director agrees to read the tittle 22 regulation section 101212 regarding reporting requirements. The Director agrees to write a statement outlining her understanding of the regulation and her plan to stay in compliance with regard to reporting requirements in a timely manner and submit to LPA Carbullido by POC due date 07/21/2021
8
9
10
11
12
13
14
Based upon record review during course of another investigation, LPA learned on 6/11/21 the facility did not report to the department a suspected case of child abuse on 06/03/21 per title 22 reporting requirements by the next business day. This is a potential health and safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2