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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830481
Report Date: 11/14/2022
Date Signed: 11/29/2022 07:45:56 AM

Document Has Been Signed on 11/29/2022 07:45 AM - 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:CHILDRENS LIGHTHOUSE OF RIVERSIDE, CAFACILITY NUMBER:
334830481
ADMINISTRATOR:BONNIE ACOSTAFACILITY TYPE:
850
ADDRESS:19743 LURIN AVENUETELEPHONE:
(951) 653-6688
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY: 128TOTAL ENROLLED CHILDREN: 128CENSUS: 24DATE:
11/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Bonnie AcostaTIME COMPLETED:
08:45 AM
NARRATIVE
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On 11/14/22 at 8:15 AM, a case management visit was completed by Licensing Program Analyst (LPA) Giselle Carbullido due to a deficiency found during the course of another inspection.

1) Personal rights: (1) To be accorded dignity in his/her personal relationships with staff and other persons. During video review, LPA observed a staff member hold a child under their arm and re-position the child towards them. After speaking to the child, the staff member let go of the child’s arm and the child walked away without appearing in distress or pain.


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. 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: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
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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Document Has Been Signed on 11/14/2022 08:35 AM - It Cannot Be Edited


Created By: Giselle Carbullido On 11/14/2022 at 05:39 AM
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: CHILDRENS LIGHTHOUSE OF RIVERSIDE, CA
FACILITY NUMBER: 334830481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
101223(a)(1)

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101223(a)(1) Personal Rights
(1) To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement is not met as evidenced by-

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Facility Director will submit proof of behavior management training to include agenda topics for S1 to the department by POC due date 11/18/22.
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Based on LPA review of facility video, the facility did not meet the section above in that facility video revealed S1 get ahold of and pull a child by the arm for redirection. This is a potential health and safety risk to persons in care.


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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.
SUPERVISOR'S NAME:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022


LIC809 (FAS) - (06/04)
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