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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700075
Report Date: 06/18/2024
Date Signed: 06/18/2024 02:19:31 PM

Document Has Been Signed on 06/18/2024 02:19 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 SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:LIBBY LAKE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
376700075
ADMINISTRATOR/
DIRECTOR:
CARMEN S. MACIASFACILITY TYPE:
850
ADDRESS:489 CALLE MONTECITOTELEPHONE:
(760) 754-1270
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 20DATE:
06/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:34 PM
MET WITH:Site Supervisor Carmen Macias TIME VISIT/
INSPECTION COMPLETED:
02:29 PM
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On the above listed date and time, Licensing Program Analyst (LPA), Kelly Gerth, arrived at the facility for the purpose of conducting a Case Management visit regarding an unusual incident report that was first reported via the duty line on 05/28/2024 by the facility and submitted via UIR report on 05/29/2024. LPA met with facility representative, Site Supervisor Carmen Macias, to discuss the reported incident.

Per Unusual Incident Report, it was reported that on 05/24/2024, C1 was observed to have been playing outside, tripped on own foot on concrete paved path, and fallen on own left arm.

Witnessing Staff, (S2), immediately contacted the parent, who then picked up C1 within 5 minutes of the phone call and took C1 to be seen by doctor.

Parent of C1 updated S2 later the same day and reported that C1 had sustained a broken left elbow and placed in a cast.

LPA determined that the facility took the necessary steps to ensure children's safety, including providing first aid and contacting the child’s parents immediately following the incident. Based on the information and interviews of 3 staff members obtained during the visit, there appears to be no violations of Title 22 Regulations pertaining to the reported incident.
An exit interview was held with Site Supervisor Carmen Macias, Notice of Site visit was issued, along with a copy of this report.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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