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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334843991
Report Date: 11/07/2022
Date Signed: 11/07/2022 10:40:00 AM

Document Has Been Signed on 11/07/2022 10:40 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:RSD-BOULDER RIDGE PRESCHOOLFACILITY NUMBER:
334843991
ADMINISTRATOR:RODRIGUEZ, VANESSAFACILITY TYPE:
850
ADDRESS:27327 JUNIPERO ROADTELEPHONE:
(951) 928-2924
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 25TOTAL ENROLLED CHILDREN: 46CENSUS: 16DATE:
11/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jessica HuffmanTIME COMPLETED:
11:00 AM
NARRATIVE
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On November 7, 2022 at 09:50AM, Licensing Program Analyst (LPA) Alaina Wilburn conducted a case management visit in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on October 24, 2022. It indicates that Classroom #9 door was open and at some point Child #1 (C1) exited the room without Staffs knowledge. C1 was found on the playground by C1's parent, who returned to C1 to the classroom. The incident occurred on October 19, 2022, where C1 was left unattended and is identified on the LIC811 (Confidential Names)”.

Facility records were reviewed and copies received. LPA interviewed Director in regards to incident, and she emailed LPA a copy of statements from all Staff who were present that day and other supportive documentation. Based on the information gathered, facility failed to comply with Care and Supervision per regulation section 101229(a)(1) Care and Supervision, which specifies: No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).

If a civil penalty has been assessed during this inspection, payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. You will receive an invoice in the mail. Do not send money until you receive your invoice. Do not send cash.

See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Division. Chapter 12.

An exit interview was conducted, and this report was reviewed with the Director Jessica Huffman. 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: Stephanie Hudak
LICENSING EVALUATOR NAME: Alaina Wilburn
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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 11/07/2022 10:40 AM - It Cannot Be Edited


Created By: Alaina Wilburn On 11/07/2022 at 09:50 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: RSD-BOULDER RIDGE PRESCHOOL
FACILITY NUMBER: 334843991

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation. The requirement is not met as evidenced by:
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Director advised she immediately met with staff during an In-Service training. They discussed active supervision, counting students frequently and the door is not allowed to be open during operation hours. There is another Staff Meeting on 12/14/2022, where someone from RCOE will be present to conduct a hands on
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The facility submitted an Unusual Incident Report dated October 19, 2022, which reported that the classroom door was open and Child #1 (C1) exited the room without staffs awareness and was found by parent on the playground and returned to room, which poses an immediate health, safety or personal rights risk to persons in care.
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Active Supervision with all staff. In addition, staff were informed that they must contact Director immediately. Lastly, Director met with parents the next day, to go over the plan of action. A zero tolerance civil penalty will be issued for child being left unattended. Director will ensure the LIC 9224s are completed within 24 hours.

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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:Stephanie Hudak
LICENSING EVALUATOR NAME:Alaina Wilburn
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022


LIC809 (FAS) - (06/04)
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