Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364830076
Report Date: 11/06/2019
Date Signed: 11/06/2019 02:57:51 PM

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:ZAGHLOUL FAMILY CHILD CAREFACILITY NUMBER:
364830076
ADMINISTRATOR:ZAGHLOUL YUDELKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 361-2240
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:14CENSUS: 8DATE:
11/06/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Yudelka ZaghloulTIME COMPLETED:
03:05 PM
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A case management visit is being conducted by Licensing Program Analyst (LPA), Marlene Wong, in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 10/10/19. It indicates that a child fractured his arm.

Child #1 was playing tag with other children and running around in the backyard. Child #2 was tagging Child #1 and pushed him to the ground. Child #1 landed with his left arm underneath his body. The licensee text the parents and Child #1's mother picked him up and took him to the doctor. The doctor diagnosed Child #1's arm as being fractured.

Based on information gathered, the incident was an accident and the facility acted appropriately. No violations have been identified.

An exit interview was conducted with Ms. Zaghloul and a copy of this report was left at the facility.

A Notice of Site Visit was issued and Analyst observed Ms. Zaghloul post the notice.

A copy of this report must be made available to the public for three years.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Marlene WongTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2019
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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