334840745-11-22-2022-10-CC-SHAA-CLENHP-20221122092903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334840745
Report Date: 11/22/2022
Date Signed: 11/22/2022 09:29:09 AM

Document Has Been Signed on 11/22/2022 09:29 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME:	FSA-OLIVEWOOD CDC		FACILITY NUMBER:	334840745
ADMINISTRATOR:	LACY HUGHES		FACILITY TYPE:	850
ADDRESS:	23268 OLIVEWOOD PLAZA DR.		TELEPHONE:	(951) 924-6100
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY: 144	TOTAL ENROLLED CHILDREN: 156	CENSUS: 21	DATE:	11/22/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Lacy Hughes		TIME COMPLETED:	09:40 AM

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On date and time listed, Licensing Program Analyst (LPA) Sumayya Habeebulla arrived at the facility to conduct a Case Management visit in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the department on 11/03/22. The incident involved child #1 and a staff in the classroom – Room 2. C1 claimed that a staff hit C1’s head softly. C1 did not specify which staff it was and was unable to recall who it was. C1 also stated that staff was angry was angry at C1 for not listening.

See Confidential Names list (LIC811).

LPA interviewed S1 and S2 regarding the UIR incident. C1 was transferred to Room 5 as per Parental Request beginning 11/08/22. S1 and S2 stated that as a typical 3- or 4-year-old, C1 has a hard time when asked to clean up and choose another center. On the day of the incident, it was observed by both staff that C1 was not in a very good mood and was finding it more difficult to follow the teachers’ requests. On the day of the incident, during center activity time, children were asked to pick a center to work in and when it was C1’s turn the Play dough table was full. C1 was asked to choose a different center. C1 worked in a different center and then wanted to join the play dough table. Teachers requested C1 to wait for her turn and C1 got upset. As per the staff, C1 threw herself on the floor and was not having it. S1 tried to soothe her but C1 was not able to calm down. Another child at the Play dough table offered to switch with C1 and C1 got up and sat at the play dough table.

SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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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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-OLIVEWOOD CDC	FACILITY NUMBER: 334840745
	VISIT DATE: 11/22/2022

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S1 also stated that at times during outdoor play, when they take a head count of the children, staff touch the children’s’ head gently while counting but she was unable to recall if they did it on that day.

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.

NO DEFICIENCIES WERE CITED DURING THIS VISIT.

An exit interview was conducted, and this report was reviewed with the Director Lacey Hughes. Appeal rights were discussed and provided during the exit interview.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

LIC809 (FAS) - (06/04)

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