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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364845858
Report Date: 09/12/2023
Date Signed: 09/12/2023 10:21:49 AM

Document Has Been Signed on 09/12/2023 10:21 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:BONNER FAMILY CHILD CAREFACILITY NUMBER:
364845858
ADMINISTRATOR:BONNER,JAZMINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 238-9459
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
09/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jazmine BonnerTIME COMPLETED:
10:40 AM
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On 9/12/23 at 8:15 am, Licensing Program Analyst Patricia Berry conducted a case management visit in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 9/6/23. It indicates a child fell from a chair and child's tooth fell out, from the fall.

Facility records were reviewed and staff and authorized representative interviewed. Based on information gathered, no violations have been identified at this time and the incident has been determined to be an unfortunate accident. The licensee immediately called the police. Licensee informed community care licensing, authorized representative, and administered first-aid.

During the tour of the facility, LPA observed the area where the child fell from the chair. LPA observed the chair has been removed from the area.

An exit interview was conducted and a copy of this report was provided to the licensee, appeal rights and notice of site visit issued.

Notice of site visit must be posted or 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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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