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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600099
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:01:46 PM


Document Has Been Signed on 10/13/2022 03:01 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 STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:LA PETITE ACADEMY INCORPORATEDFACILITY NUMBER:
376600099
ADMINISTRATOR:RIVAS, OBDOLIAFACILITY TYPE:
850
ADDRESS:725 SHADOWRIDGETELEPHONE:
(760) 727-0648
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:96CENSUS: 32DATE:
10/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Obdulia RivasTIME COMPLETED:
03:10 PM
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On October 13, 2022, Licensing Program Analyst (LPA), Jessica Rubio arrived at the La Petite Academy Incorporated (CCC) to follow up on an unusual incident report dated 9/30/2022 for an incident that occurred on 9/28/2022 involving C1 falling and later requiring medical attention. LPA interviewed the Director and the staff present during the incident. Interviews revealed C1 did fall while running outside on the playground area and that there were one teacher and one aid providing supervision of 14 children. The Assistant Director was also present in the playground. Interviews revealed after C1 fell, C1 did cry, however was not observed to have any bruises or injuries. Interviews revealed C1 returned to their normal activities after falling and did not complain or show signs of being in pain for the remainder of the day. Interviews revealed an incident report was written up however was not provided to the parent of C1 until the next day 9/29/2022 when it was determined C1 was injured. Upon being notified of C1 being injured and requiring medical attention, the CCC did submit an unusual incident report.

Based on information gathered, the CCC acted appropriately and no violations have been identified. An exit interview was conducted, appeal rights discussed and a copy of this report was provided to Director Obdulia Rivas. The Director was also provided with a Notice of Site Visit and reminded that this notice must be posted for 30 days.
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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