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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846079
Report Date: 05/10/2024
Date Signed: 05/10/2024 10:07:25 AM

Document Has Been Signed on 05/10/2024 10:07 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:FORTUNE PRESCHOOLFACILITY NUMBER:
364846079
ADMINISTRATOR/
DIRECTOR:		SAHLAH STORKSFACILITY TYPE:
850
ADDRESS:655 W 2ND STTELEPHONE:
(909) 884-1410
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92410
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 12DATE:
05/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:SAHLAH STORKSTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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On 05/10/2024 Licensing Program Analyst (LPA) Justin Giese made an unannounced visit to the facility to conclude the investigation of an Unusual Incident Report (UIR). The UIR outlined an incident which occurred on 04/30/2024 pertaining to Admission Agreements. LPA met with Director Sahlah Storks and discussed the following.

On 05/06/2024 LPA made an unannounced visit to the facility to for the purpose of gathering more information pertaining to the submission of this UIR. The UIR outlined an incident regarding the release of a child to named authorized individuals listed on the child's emergency contact paperwork. An amendment was made to the original document, however; the proper paperwork granting custody and limiting who could remove the child was not provided.

LPA conducted an interview with the Director and reviewed facility files, facility handbook policy and pertinent documents. After reviewing said documents it has been determined no licensing violations had occurred. Facility will adhere to their admissions agreement/handbook and only make alterations to emergency contact paperwork when the appropriate documents are provided by authorized representatives.

An exit interview was conducted, LPA provided the Director, Sahlah Storks with a copy of this report and a notice of site visit on 05/10/2024.

Notice of Site Visit must remain posted for the next 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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