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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503808958
Report Date: 04/04/2022
Date Signed: 04/04/2022 11:03:44 AM

Document Has Been Signed on 04/04/2022 11:03 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:MODESTO CHRISTIAN PRESCHOOLFACILITY NUMBER:
503808958
ADMINISTRATOR:HALEY COSTAFACILITY TYPE:
850
ADDRESS:5755 SISK ROADTELEPHONE:
(209) 343-2321
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 42DATE:
04/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Haley CostaTIME COMPLETED:
11:15 AM
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On April 4, 2022, Licensing Program Analyst (LPA) Kari McWilliams conducted an unannounced case management inspection. LPA toured the facility and a census was taken. LPA met with facility director, Haley Costa. The purpose today's inspection was to discuss an incident that occurred on March 29, 2022. A complete file review was conducted prior to today's inspection.

An Unusual Incident Report was submitted to the Fresno Community Care Licensing Office regarding an incident that occurred on March 29, 2022 where Child #1 was climbing a play structure and fell and broke her right arm. Today, LPA spoke with an attending staff member who stated that on the date of the incident, there were 15 children outside and two staff members when child #1's hand slipped off the bar of the structure and fell on her right arm. Director stated that there was a staff member about four feet away from child #1 and was to the side of child #1. Director states that child #1 fell approximately 4 feet off the ground. Director reported that staff escorted child #1 to table and called over Director. Director consoled child #1 and gave child #1 an ice pack but child #1 did not want the ice pack. Director stated that child #1 did not have a big reaction and the other children were able to keep playing as Director was able to take care of child #1 needs.

Director stated that she took pictures of both elbows and sent to mom; right elbow was observed as being a little red and lightly swollen. Mom picked up child #1 and took her to the emergency room where it was determined that child #1 right arm was broken below the elbow.

LPA McWilliams observed the dome climbing structure and was able to determine that the ground has adequate padding with artificial turf and padding underneath.

Director states that there is no directives from doctor on limitations of child #1; there is no additional care needed to provide to child #1 that takes away from other children in center.

Per Chapter 1, Division 12, Title 22 of the California Regulations, there are no deficiency’s being cited at this time. An Exit interview was conducted with Director Costa. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Kari McWilliams
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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