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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846163
Report Date: 08/24/2022
Date Signed: 08/24/2022 11:47:22 AM

Document Has Been Signed on 08/24/2022 11:47 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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KIDDIE ACADEMY OF CORONAFACILITY NUMBER:
334846163
ADMINISTRATOR:HERNANDEZ, JAZMINEFACILITY TYPE:
830
ADDRESS:3977 BEDFORD CANYON RDTELEPHONE:
(951) 444-7434
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY: 40TOTAL ENROLLED CHILDREN: 21CENSUS: 12DATE:
08/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Payal Kotadiya, Licensee
Jazmine Hernandez, Director
Ann Marie Montoya, Director (Training)		TIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Elyse Jones and Blanca Ruiz arrived at the facility to conduct a Case Management inspection in response to the receipt of an Unusual Incident Report (UIR) from the facility. The UIR was received by the licensing agency on 8/16/2022. In the UIR it states Child #1 was inadvertently given Child #2's bottle during the noon feeding. Children's bottles were labeled and dated however, staff did not read the label prior to feeding the bottle to Child #1. Parents of each child were notified and no allergic reactions were noted. Director provided staff training which included but was not limited to bottle feeding, attention to detail, allergies and communication.

At the time of the inspection, LPAs toured the facility, took census, and met with Director, Jazmine Hernandez. Additional interviews with pertinent parties were conducted to obtain details regarding the reported incident.

Records were reviewed and staff were interviewed. Based on the information gathered, the following violation has been identified:

101427 Infant Care Food Service


(c) The infant shall be fed in accordance with the individual plan.

See Lic 809D for cited deficiencies of the California Code of Regulation, Title 22, Div. 12

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KIDDIE ACADEMY OF CORONA
FACILITY NUMBER: 334846163
VISIT DATE: 08/24/2022
NARRATIVE
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An exit interview was conducted, appealed rights discussed, Notice of Site Visit and a copy of this report was provided to facility Director, Jennifer Hernandez.

A copy of this report must be made available to the public at the facility site, for 3 years.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/24/2022 11:47 AM - It Cannot Be Edited


Created By: Elyse Jones On 08/24/2022 at 11:12 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KIDDIE ACADEMY OF CORONA
FACILITY NUMBER: 334846163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2022
Section Cited
CCR
101427(c)

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Infant Care Food Service
(c) The infant shall be fed in accordance with the individual plan.
This requirement was not met as evidenced by:
Based on the interview and record review, the Licensee did not meet Infant Care Food Service regulation which poses a potential
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During the inspection the Director provided an Action Plan with topics discussed during training.

Deficiencies cleared during spection.
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Health, Safety & Personal Rights risk to the children in care. During record review the facility self-reported that Child # 1 was given Child # 2’s bottle. Pertinent parties confirmed this to be true during interviews. Per Child #1’s Infant and Toddler Schedule he/she should have been given milk but he/she was given formula.
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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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022


LIC809 (FAS) - (06/04)
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