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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334841761
Report Date: 08/04/2025
Date Signed: 08/04/2025 01:52:34 PM

Document Has Been Signed on 08/04/2025 01:52 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:RUSD/ADAMS ELEMENTARY SCHOOLFACILITY NUMBER:
334841761
ADMINISTRATOR/
DIRECTOR:		LARI NELSONFACILITY TYPE:
850
ADDRESS:8362 COLORADO AVENUETELEPHONE:
(951) 352-6709
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 0DATE:
08/04/2025
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Luz RomeroTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On day and time listed above Licensing Program Analyst (LPAs), Giselle Carbullido arrived at the facility to conduct a Licensee initiated case management inspection with facility representative, Luz Romero. Facility is requesting a room change from current classroom K5 to proposed classroom 1. During the visit, LPA inspected purposed classroom 1 for the preschool program with no change in capacity.
LPA observed the following:
A fire inspection report was completed however fire clearance for capacity is still pending. LPA received an updated facility sketch prior to visit.
The room is equipped with age appropriate furniture and the equipment is in good condition The floors and room appear to be clean, safe and free from hazards and debris Hazards, including poisons and toxins were not observed and are stored inaccessible to children Medications are stored in the health office The facility has a functioning carbon monoxide and smoke detector There is contaminated water supply from indoor and outdoor water fountains per lead testing. Lead testing was completed on 06/28/25 and results report identified lead exceedances in the following outlets: A (19 ppb); B (15ppb); and C (23ppb) See LIC809D for deficiency cited. Facility has initiated remediation (repairs) for retesting. Facility will provide store bought bottled water for indoor and outdoor use until remediation is complete.
LPA toured the facility and obtained the following measurements: Classroom 1 indoor activity space: LPA has determined that there is sufficient space to accommodate current capacity of 24 children.
Outdoor Activity Area: No changes to outdoor activity space; and per Prelicnese report is sufficient to accommodate 162 children.
NAME OF LICENSING PROGRAM MANAGER: Gilbert Sena
NAME OF LICENSING PROGRAM ANALYST: Giselle Carbullido
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: RUSD/ADAMS ELEMENTARY SCHOOL
FACILITY NUMBER: 334841761
VISIT DATE: 08/04/2025
NARRATIVE
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 LPA observed waivers on file share playground and bathrooms with elementary school.
The preschool room 1 is in substantial compliance.
During the exit interview, a copy of this report and notice of site visit was provided to facility representative. Luz Romero.
NAME OF LICENSING PROGRAM MANAGER: Gilbert Sena
NAME OF LICENSING PROGRAM ANALYST: Giselle Carbullido
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2025 01:52 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 08/04/2025 at 01:03 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: RUSD/ADAMS ELEMENTARY SCHOOL
FACILITY NUMBER: 334841761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
CCR
101700.3(b)(2):

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101700.3 (b)(2): Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care. This requirement is not met as evidence by:
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Facility will implement corrective action pursuant to section CCR 101704 for immediate cessation of outlets testing with action level exceedance until it is replaced and retested pursuant to section CCR 101705 and returns a result at or below
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Based on records review of required lead testing, the facility had lead values of 5 or above on water outlets: A (19 ppb); B (15ppb); and C (23ppb). This is a potential health and safety risk to persons in care.
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 the Acton level. Facility will notify CDSS with completion within 30 days.

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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.
Gilbert Sena
NAME OF LICENSING PROGRAM MANAGER:
Giselle Carbullido
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


LIC809 (FAS) - (06/04)
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