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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364815524
Report Date: 09/14/2023
Date Signed: 09/14/2023 11:35:19 AM

Document Has Been Signed on 09/14/2023 11:35 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:FUSD-DOROTHY GRANT ELEMENTARYFACILITY NUMBER:
364815524
ADMINISTRATOR:DARCY WHITNEYFACILITY TYPE:
850
ADDRESS:7069 ISABEL LANETELEPHONE:
(909) 357-5540
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 15DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Darlene JohnsonTIME COMPLETED:
11:40 AM
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On date and time listed above, Licensing Program Analyst, Giselle Carbullido conducted a case management visit conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 09/11/23 and indicates an inappropriate action between children.

LPA conducted staff interviews and obtained facility documentation. Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the facility representative.

An exit interview was conducted and a copy of this report, appeal rights, and notice of site visit were provided to facility representative, Darlene Johnson.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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