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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360904126
Report Date: 05/10/2023
Date Signed: 05/10/2023 04:19:49 PM

Document Has Been Signed on 05/10/2023 04:19 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:FAITH LUTHERAN DAY CARE CENTERFACILITY NUMBER:
360904126
ADMINISTRATOR:HEATHER URIBEFACILITY TYPE:
850
ADDRESS:12449 CALIFORNIA STREETTELEPHONE:
(909) 790-1816
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 24DATE:
05/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Heather UribeTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Aman Sharma was at the facility on another matter. A case management inspection was also conducted to follow-up on an unusual incident report submitted by the facility on 04/27/2023. It was reported that while on the playground at 4:48pm on 04/26/2023, a child lost their grip and fell back, landing on their right shoulder.

During the inspection, LPA toured the facility, including where the reported incident took place, took census, and met with Director, Heather Uribe to discuss the reported incident.

During this inspection, LPA spoke with pertinent parties; staff involved in the incident when it took place, and the subject child(ren) involved in the incident. It was disclosed that a child sustained a broken Humerus as a result of slipping off the play structure they were playing on outside. This incident occurred as staff was releasing another child to their authorized representative for dismissal for the day. LPA checked the area of the play structure and ensured that there is mulch as a soft landing for children while playing outside.

Based on all the information obtained during the visit, as well as an inspection of the play structure where the incident occurred, there appeared to be no violations of Title 22 Regulations pertaining to the incident reported.

An exit interview was held with Director, Heather Uribe. A Notice of Site visit was issued, along with a copy of this report.

This report shall be public record for three years.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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