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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334840745
Report Date: 09/15/2022
Date Signed: 09/15/2022 12:39:40 PM

Document Has Been Signed on 09/15/2022 12:39 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-OLIVEWOOD CDCFACILITY NUMBER:
334840745
ADMINISTRATOR:LACY HUGHESFACILITY TYPE:
850
ADDRESS:23268 OLIVEWOOD PLAZA DR.TELEPHONE:
(951) 924-6100
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 144TOTAL ENROLLED CHILDREN: 144CENSUS: 23DATE:
09/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:56 AM
MET WITH:Lacey HughesTIME COMPLETED:
12:39 PM
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On September 15, 2022 at 11:56 AM, a case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the facility on 09/02/22. The incident involved child #1 and staff #1, stating that S1 had pushed down C1 on 08/29/22 while outside. See Confidential Names list (LIC811).

LPA interviewed S1 and S2 and observed the classroom during transition time. Based on information gathered, the facility acted appropriately, and no violations have been identified. Director, Lacey Hughes submitted an unusual incident report, observed the classroom in question, interviewed teachers and communicated with parents and immediately reported the incident to this agency.

An exit interview was conducted and a copy of this report, LIC811 was provided to facility staff

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Anastasia Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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