364846066-9-21-2023-09-CC-JGIE-CVVRXW-20230921132524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364846066
Report Date: 09/21/2023
Date Signed: 09/21/2023 01:25:31 PM

Document Has Been Signed on 09/21/2023 01:25 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/MILL CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	364846066
ADMINISTRATOR:	SOARES, CHERYL		FACILITY TYPE:	850
ADDRESS:	205 SOUTH ALLEN STREET		TELEPHONE:	(909) 383-2025
CITY:	SAN BERNARDINO	STATE: CA	ZIP CODE:	92408
CAPACITY: 160	TOTAL ENROLLED CHILDREN: 160	CENSUS: 79	DATE:	09/21/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:17 AM
MET WITH:	Cheryl Soares		TIME COMPLETED:	01:35 PM

NARRATIVE

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On date and 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 09/05/2023. LPA met Site Supervisor, Cheryl Soares, to discuss the purpose of the visit.

On 09/05/2023 Facility Staff self-reported an incident that occurred on 08/29/2023. UIR stated a child in care was observed to have a light pink scratch around 1 inch in length under their left eye. The scratch was observed by the Child’s Authorized Representative and reported to staff at time of pick up, approximately 04:24pm on 08/29/2023.

On 09/21/2023 LPA Giese made an unannounced visit to the facility to follow-up with pertinent parties involved regarding the submitted incident report. LPA reviewed/collected documents and conducted interviews with staff present the day the incident had occurred as well as the subject child. All parties interviewed corroborated no notable incidents had occurred that would have resulted in the child receiving a scratch under the eye, however; the scratch, once reported was documented by the facility. LPA was provided with an internal incident report nothing date of incident and details of the observed scratch under the Child’s eye.

Statements recorded form interviewing all parties involved revealed the cause or event leading to an observed scratch under the child’s eye were unknown. Based on LPA observations and interview there appear to be no violations of Title 22 at this time. The authorized representative of the child was provided an incident report documenting the observed scratch under the Child’s eyes and the Facility fulfilled its reporting requirements to Licensing by submission of an UIR.

An exit interview was conducted, LPA provided Site Supervisor, Cheryl Soares with a copy of this report and a notice of site visit on 09/21/2023.

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

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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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