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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910907
Report Date: 07/05/2023
Date Signed: 07/05/2023 03:39:17 PM


Document Has Been Signed on 07/05/2023 03:39 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 ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:KID'S CLUBFACILITY NUMBER:
360910907
ADMINISTRATOR:ADAMS, CHERIEFACILITY TYPE:
840
ADDRESS:1825 N. VINEYARDTELEPHONE:
(909) 985-7279
CITY:ONTARIOSTATE: CAZIP CODE:
91764
CAPACITY:57CENSUS: 25DATE:
07/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kristine RamosTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPA), Aman Sharma conducted a required annual inspection. LPA was met with site director, Kristine Ramos. An inside out tour of the facility was given, and the following was observed and/or noted:
This facility is also licensed for a preschool program, which was also inspected on this date.
· The licensee/director is asked to update the following documents, if applicable, and submit to licensing within 30 days:
1. LIC 500 Personnel Report
2. LIC 610 Emergency & Disaster Plan
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made)
4. LIC 309 Administrative Organization
· LIC 308 Designation of Administrative Responsibility
The following items have been posted and are updated where necessary:
- License
- Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
- Parent’s Rights Poster (PUB393)
- Personal Rights (LIC613A)
- Child Car Seat Law
-See something, say something poster
- Food menu.
· The facility is operating with the limits as stated on the license.
· Ratios were being met during this inspection
· Classrooms are adequately equipped with age and size appropriate furniture. All equipment are free of hazards.
· There are no weapons present at the facility
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 805-5718
LICENSING EVALUATOR NAME: Aman SharmaTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KID'S CLUB
FACILITY NUMBER: 360910907
VISIT DATE: 07/05/2023
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·There are no accessible bodies of water present. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Children bring their own water bottles to utilize in both, indoor and outdoor activity spaces.
· Uncontaminated drinking water was observed and is used to refill water bottles, as needed
· No medications are currently being used at the facility.
· Hazards are also stored where they are inaccessible to children. These items include: Disinfectants, cleaning solutions and other items that are dangerous to the health and safety of children in care.
· Poisons and toxins are kept unreachable and locked.
· All floors were observed clean and safe and shall remain so at all times.
· Restrooms were observed to be sanitary and in operating condition
· Playgrounds are enclosed by appropriate fences. Director was reminded to constantly assess play structures from being disposed of, if they pose a threat to the health and safety of children.
· Outdoor activity areas are in good condition and supplied with age/size appropriate equipment.
· The areas around or under high climbing equipment, swings, slides, and similar equipment were cushioned with material that absorbs a fall.
· Food preparation area is clean, free of litter, rubbish and free of rodents and other vermin
· Food is stored appropriately and protected from contamination
· All storage containers for solid waste, including moveable bins have tight-fitting covers that were observed to be on and in good repair- SEE LIC9102
· Menus were posted with date included and were placed in a visible location of children’s authorized representatives. Menus shall be kept on file for 30 days, and made available upon request.
· Sign in/Sign out record was reviewed and meet regulation requirements.
· All staff members present had a current Pediatric CPR/First Aid on file.
· Director completed Health and Safety Training, which is on file.
· A review of children’s records were found to be complete during this inspection-SEE LIC809D
· Disaster drills are to be conducted every six months – last drill was conducted on 06/22/23
· The Director was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 805-5718
LICENSING EVALUATOR NAME: Aman SharmaTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KID'S CLUB
FACILITY NUMBER: 360910907
VISIT DATE: 07/05/2023
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·The Director can submit transfer forms to associate or disassociate someone from their facility at: Associations_Disassociations862@dss.ca.gov
· A review of staff records indicates that staff that were present meet minimum qualifications for the position for which they were hired.
- This facility does not currently provide Incidental Medical Services (IMS). LPA reviewed where storage of medication and equipment/supplies would be, and discussed children’s, personnel, and administrative records to be completed as needed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.

-The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

- Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

- To access on-line Licensing forms & Regulations for a Child Care Center please visit: www.ccld.ca.gov.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:


1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

Exit interview conducted and report was reviewed with the site director, Kristine Ramos.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 805-5718
LICENSING EVALUATOR NAME: Aman SharmaTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/05/2023 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: KID'S CLUB
FACILITY NUMBER: 360910907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status as specified in Section 101220, and the following health information: (C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not comply with the section cited above in 1 out of 5 children. One child was missing a signature on the LIC927, Consent for Emergency Medical Treatment. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Director agrees to get the LIC927, Consent for Emergency Medical Treatment form signed by parent/authorized representative no later than POC due date. Director also agrees to submit proof of completion to licensing no later than Friday, 07/07/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kimberly WilliamsTELEPHONE: (951) 805-5718
LICENSING EVALUATOR NAME: Aman SharmaTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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