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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364801214
Report Date: 04/06/2023
Date Signed: 04/06/2023 02:08:22 PM

Document Has Been Signed on 04/06/2023 02:08 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:PSD/ONTARIO HEAD STARTFACILITY NUMBER:
364801214
ADMINISTRATOR:WILLIAM ALVAREZFACILITY TYPE:
850
ADDRESS:555 W. MAPLE AVENUETELEPHONE:
(909) 984-4117
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 224TOTAL ENROLLED CHILDREN: 224CENSUS: 66DATE:
04/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Williams Alvarez TIME COMPLETED:
02:20 PM
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A case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. LPAs met with Director, William Alvarez. The center was toured, and a census was taken. The UIR was received by the licensing agency, and it indicates a child’s fingers were stuck in a door in Classroom N.95. Facility records were reviewed, and interviews were conducted with Site Director and pertinent parties.

Per information obtain during this inspection, Staff N.1 and Staff N.2 were providing care and supervision to 6 children in the classroom. At the time of the incident, Staff N.2 was setting tables for lunchtime, and Staff N.1 was dancing and singing with children. Staff N.1 noticed that Child N.1 was by the door squatting, and it was assumed that the child was going to the restroom and did not want to disturb the child. Few seconds later, Child N.1 cried and scream “ow.” Staff N.1 immediately stopped and check on the child.

As Staff N.1 approached Child N.1 it was observed that child’s finger was stuck under the front classroom door (opening was approximately 1/2 inch gap). Staff N.1 pushed the door open and released the child’s finger. Child’s middle finger (left hand) was swollen, red, bleeding and some skin peeled off. Staff comforted child, cleaned the cut and applied ice. Child’s Authorized Representative (AR) was called immediately and arrived at the facility within 30 minutes. Staff advised AR to take child to the doctor to rule out any concerns. Child N.1 in non-verbal due to age. Therefore, LPA Ruiz called the AR of the child and information provided by child’s AR confirm that child returned to the facility the following day and child is doing well. Child was taken to Urgent Care on the day of the incident but parent decided not to seek medical attention. It was stated the child had a scrap and the facility informed her of the incident and spoke with her to make sure the child was doing well.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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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: PSD/ONTARIO HEAD START
FACILITY NUMBER: 364801214
VISIT DATE: 04/06/2023
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During this inspection, LPAs observed Classroom N.95 where the incident took place and the adjacent classroom which is currently used as an office; both doors had a door guard( door skirt/ door sweep) to prevent future incident from occurring.

Based on information gathered, LPA was able to determine that an incident did occur; however, facility acted appropriately by providing First Aid, reporting the incident to the parent and Community Care Licensing as soon as it happened. Facility also took immediate action by installing door guards to prevent future incidents. Facility also maintained close communication with parent and follow up regarding child’s health condition. Child is still enrolled at the facility. There appears to be no violation of Title 22 Regulation pertaining to the reported incident at this time.

Exit interview conducted and report was reviewed with Director, William Alvarez. Appeal rights were discussed, and a notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC809 (FAS) - (06/04)
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