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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911249
Report Date: 04/23/2025
Date Signed: 04/23/2025 11:11:24 AM

Document Has Been Signed on 04/23/2025 11:11 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:FUSD/LOCUST ELEMENTARYFACILITY NUMBER:
360911249
ADMINISTRATOR/
DIRECTOR:		DARCY WHITNEYFACILITY TYPE:
850
ADDRESS:7420 LOCUST AVENUETELEPHONE:
(909) 357-5650
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 11DATE:
04/23/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Gabriela Amezcua - Permit TeacherTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 04/23/2025 at time listed above Licensing Program Analysts (LPA) Justin Giese conducted an unannounced visit to the facility to follow up on the submission of an Unusual Incident Report (UIR) that was received by the Regional Office on 04/15/2025 and processed on 04/17/2025. LPA met with Permit Teacher, Gabriela Amezcua, to discuss the purpose of the visit.

On 04/11/2025 Facility Staff self reported an incident where a child in care sustained an injury on the playground. UIR stated that around 10:15am children were playing on the outdoor playground. The subject child tripped on a “hoola hoop”, and fell to their left side, scraping their left knee. It was reported the fall was witnessed by staff. The child was able to pick themselves up after the fall, staff observed the child sustained a scrape and was favoring their left arm.

The parent/guardian of the child was contacted, and the child was picked up shortly after incident. UIR stated the parent/guardian contacted the facility the following day to inform that the child had been seen by their physician, and it was determined they sustained a slight fracture to their left elbow. The child was given a soft cast for recovery. The child was stated to be stay home under parental supervision and would return to the facility when they are released by their physician.

The subject child of this incident was not present at the facility at time of this visit. LPA was unable to interview subject child.

NAME OF LICENSING PROGRAM MANAGER: Gilbert Sena
NAME OF LICENSING PROGRAM ANALYST: Justin Giese
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: FUSD/LOCUST ELEMENTARY
FACILITY NUMBER: 360911249
VISIT DATE: 04/23/2025
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At time of this visit, LPA Interviewed staff involved in this incident and toured the facility playground where the incident had occurred. LPA was informed the incident occurred on the padded surface area under the playground’s play structure. It was stated the children in attendance were doing an activity by sitting in a circle around a “hoola hoop” which was used to mimic a camp fire. The children were telling campfire stories and sitting in a circle formation around the hoola hoop. It was stated that staff rang a bell to inform the children they had 5 additional minutes of play time, which signals it was time to clean up the toys on the playground and prepare to line up before returning to the classroom. Staff informed they observed the children sitting around the hoola hoop stand up and reach for the hoola hoop to pick it up after the bell had rang. The subject child in this incident stood up but and had their foot inside the ring hoola hoop, due to children picking up the hoola hoop, they unintentionally tripped the subject child, resulting in the fall.

Statements recorded form interviewing staff involved revealed the fall was accidental in nature, and caused by children unintentional tripping the subject child with a hoola hoop. Facility staff were present, providing active supervision and quick to aid the child after the fall. The authorized representative of the child was notified immediately and picked up after incident. The Facility fulfilled their reporting requirements to Licensing by submitting an unusual incident report in the appropriate time frame. Based on LPA observations and interview there appear to be no violations of Title 22 as a result of this incident.

An exit interview was conducted, and report was reviewed. LPA provided the Permit Teacher, Gabriela Amezcua with a copy of this report and issued a notice of site visit on 04/23/2025.

Notice of site visit must be displayed for the next 30 days.

NAME OF LICENSING PROGRAM MANAGER: Gilbert Sena
NAME OF LICENSING PROGRAM ANALYST: Justin Giese
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
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