<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846374
Report Date: 07/09/2024
Date Signed: 07/09/2024 02:54:32 PM

Document Has Been Signed on 07/09/2024 02:54 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:EASTER SEALS CHILD DEVELOPMENT CENTERFACILITY NUMBER:
364846374
ADMINISTRATOR/
DIRECTOR:		SHAYLENE JUDSONFACILITY TYPE:
830
ADDRESS:1102 WEST PHILLIPS STREETTELEPHONE:
(909) 981-4668
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 25DATE:
07/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Estella Perez/directorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/9/24 at 12:50 pm, LPA 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 6/28/24. It indicates that an infant was found by parent with a leaf in their mouth. Facility staff were interviewed. Staff stated they noticed the infant had leaves in their hands and they took the leaves away. Staff stated the infant was not acting their usual self. Staff stated they did inform the parent about their infant's unusual behavior. Staff stated later on they were informed the infant had a leaf in the roof of the their mouth. Staff stated they did not see the incident occur.

Based on the information gathered, the following violation has been identified: 101429 Responsibility for Providing Care and Supervision for Infants (a) In addition to Section 101229, the following shall apply: (1) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times.

See LIC809D for cited deficiencies 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.

Notice of Site Visit issued and must be posted for 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/09/2024 02:54 PM - It Cannot Be Edited


Created By: Patricia Berry On 07/09/2024 at 02:24 PM
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: EASTER SEALS CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 364846374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2024
Section Cited
CCR
101429(a)(1)

1
2
3
4
5
6
7
Responsibility ,,,and Supervision for Infants ...(a) the following shall apply: (1) Each infant shall be constantly supervised ...under direct visual observation and supervision by a staff person at all times.
This requirement was not met as evidenced by
1
2
3
4
5
6
7
Director stated she will have a staff meeting with all infant staff and send LPA the topic, a list of participants to CCL
Director stated she will also put a plan together and send the plan to LPA on how this incident will not occur in the future by 7/16/24.
this incident will not occur in the fututre.
8
9
10
11
12
13
14
Based on interviews conducted staff saw an infant with leaves in their hand and did not see the infant put a leaf in their mouth.

This is a potential risk to the health and safety of children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2