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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364809074
Report Date: 10/21/2021
Date Signed: 10/21/2021 01:17:19 PM

Document Has Been Signed on 10/21/2021 01:17 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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
364809074
ADMINISTRATOR:MORALES, ASHLEYFACILITY TYPE:
830
ADDRESS:16149 FOOTHILL BOULEVARDTELEPHONE:
(909) 823-2323
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 17DATE:
10/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Jessica Salvador-Rivera/ DirectorTIME COMPLETED:
01:45 PM
NARRATIVE
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On 10/21/2021 at 11:25 AM, Licensing Program Analyst Patricia Berry conducted a case management- deficiency investigation in response to the receipt of an unusual incident report (UIR) from the facility. LPA was granted access into the facility and met with Jessica Salvador-Rivera director. LPA toured the facility and took census. Regrading Unusual Incident Report, self reported by director on 10/15/21, a staff member gave an infant the wrong bottle. Director stated a staff member noticed another staff member feeding a child the wrong bottle. Director stated she immediately called the parents and discussed the incident with the staff members. Director stated the child had the same type of formula so there was no allergic reaction. Although there was conflicting information among staff members, director stated her district manager and herself investigated the incident and determined that a staff member gave an infant the wrong bottle.


Based on the information gathered, the following violation has been identified: 101223 (a) (2) Each child shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

See LIC809D for cited deficiency of the California Code of Regulations, Title 22, Div. 12.

An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to facility staff.

This report must be made available to the public upon request for 3 years.

Acknowledgment of receipt provided to director.

Notice of site visit issued and LPA observed director post the notice.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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Document Has Been Signed on 10/21/2021 01:17 PM - It Cannot Be Edited


Created By: Patricia Berry On 10/21/2021 at 09:11 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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 364809074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
101223(a)(2)

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Personal Rights. (a) The licensee shall ensure... (2) Each child shall be accorded safe, healthful and comfortable accommodations...

This requirement was not met as evidenced by
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Director immediately notified parents; sent unusual incident report to CCL 10/15/21. Director stated she will start inservice training on 10/21 or 10/22, on feeding practices and procedures. Director stated she will add the health risk of an infant being fed the wrong milk/formula.
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 Based on staff fed, an infant in care, the wrong bottle.


This is an immediate risk to the health, safety and personal rights of children in care.
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 Agenda and sign in sheet to be submitted by to CCL by 10/22/21.

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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:Gilbert Sena
LICENSING EVALUATOR NAME:Patricia Berry
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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