334845360-2-1-2023-10-CC-AWIN-CNMR58-20230201114243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334845360
Report Date: 02/01/2023
Date Signed: 02/01/2023 11:42:46 AM

Document Has Been Signed on 02/01/2023 11:42 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:	MUSTAFFA FAMILY CHILD CARE		FACILITY NUMBER:	334845360
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	02/01/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kathi-Jo Mustaffa		TIME COMPLETED:	11:45 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

At 10:30AM on February 1, 2023, Licensing Program Analyst (LPA) Alaina Wilburn met with Licensee Kathi-Jo Mustaffa. An unannounced 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 licensing agency on 12/21/2022. It indicates that on 12/19/2022, Child #1 (C1) and Child #2 (C2) were in the play area playing separately. C2 was sitting on the carpet building a fort, and C1 walked up and hit C2 on the head with a pillow. In response, C2 pushed C1 who fell back onto the carpet. There were no toys or objects that C1 could've fell onto, and child did not hit the wall or anything. Prior to the incident, Licensee walked out to grab her ringing phone. While grabbing the phone, Licensee heard a loud cry. When she returned to the play room, she observed C1 laying on the ground crying. Licensee thought the child was just having a meltdown. She followed the parent of C1's instructions and placed C1 in a pull & play. C1 cried and went to sleep shortly thereafter.

Facility records were reviewed and LPA received copies of relevant paperwork for C1's file. Based on information gathered, the facility acted appropriately and no violations have been identified.

An exit interview was conducted, and this report was reviewed with the licensee Kathi-Jo Mustaffa.

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: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 1