360906598-9-20-2023-09-CC-ASHA-CVUPJE-20230920112127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360906598
Report Date: 09/20/2023
Date Signed: 09/20/2023 11:21:29 AM

Document Has Been Signed on 09/20/2023 11:21 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:	CJUSD/SAN SALVADOR CHILDREN'S CENTER		FACILITY NUMBER:	360906598
ADMINISTRATOR:	MACK, MELISSA		FACILITY TYPE:	850
ADDRESS:	471 AGUA MANSA ROAD		TELEPHONE:	(909) 876-4154
CITY:	COLTON	STATE: CA	ZIP CODE:	92324
CAPACITY: 120	TOTAL ENROLLED CHILDREN: 120	CENSUS: 12	DATE:	09/20/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Melissa Williamson		TIME COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analyst (LPA) Aman Sharma arrived at the facility to conduct a case management investigation in response to the receipt of an Unusual Incident Report (UIR). The UIR was received by the Riverside Child Care Regional Office (RCCRO), on 09/11/2023. The UIR documented an incident where a child hit their head on the first step of a play structure outside. This resulted in a cut on the left side of their head, requiring medical attention.

Upon arrival, LPA met with Director Melissa Williamson and stated the purpose of the visit. Records were reviewed, and interviews were conducted.

Interviews disclosed that the subject child was playing on the play structure, when another child was climbing up another part of the same play structure. The teacher went to correct the other child, when the subject child fell and hit their head, causing a cut on the left side of their head, requiring medical attention. The school nurse was called, who then assessed the cut and called the subject child's authorized representatives.

Interviews and record review also disclosed that the subject child has trouble walking and is often times tripping and falling. The subject child returned to school on 09/14/2023 with a doctors note, and has not missed a day since.

Based on the information gathered and compiled during this case management investigation, there was no evidence of a violation of Title 22. No citations were issued at this time.

LPA conducted an exit interview with director, Melissa Williamson and provided her with a copy of this report. A Notice of Site Visit was issued and must remain posted for the next 30 days.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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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