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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501334
Report Date: 10/17/2024
Date Signed: 10/17/2024 12:52:30 PM

Document Has Been Signed on 10/17/2024 12:52 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:CLAREMONT PRESBYTERIAN CHURCH CHILDREN'S CENTERFACILITY NUMBER:
191501334
ADMINISTRATOR/
DIRECTOR:		SASKIA(SACHA)LORDFACILITY TYPE:
850
ADDRESS:1111 NORTH MOUNTAINTELEPHONE:
(909) 626-6261
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 40DATE:
10/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Saskia (Sacha) LordTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On October 17, 2024, at 9:15 am Licensing Program Analyst (LPA) Carolyn Tuba conducted a case management inspection due to an incident that was self-reported and a Unusual Incident Report (UIR) was submitted by the facility. The incident occurred on 9/13/2024 at approximately 11:00 am outside on the preschool playground. Covid risk assessment was conducted. LPA met with Director, Saskia (Sacha) Lord. LPA observed and took a census of 40 children with 7 staff.

The incident was reported to the Department within the required 24 hours of occurrence. The incident consisted with two children playing in the playhouse on the preschool playground outside and one child sustained an injury.

During this investigation, LPA conducted interviews with Director, Staff #1 (S1), and Staff #2 (S2). LPA conducted an interview with Child #1 (C1) and attempted to interview Child#2 (C2) who did not qualify.

S2 stated that C1 and C2 were playing in the playhouse on the playground and that C2 threw a toy dinosaur, which resulted in hitting C1 on the right side of the face on the temple near forehead. S1 confirmed the incident and was the person who provided first aid to C1 by cleaning the area, placing a gauze and bandage. Parents of C1 were notified by phone and picked up the child at approximately 11:25 am and later disclosed to S1 at approximately 3:00 pm my message on ProCare that C1 was taken to their local Urgent Care for medical attention. According to both S1 and S2, C2’s parent was notified of the incident and that C2 was spoken about proper play with toys. C1 disclosed to LPA and confirmed what occurred during the incident between C1 and C2 on 9/13/2024. LPA observed a small scar that resulted from the injury.

According to the Director, father of C1 informed her at a school event that evening that C1 was taken to

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CLAREMONT PRESBYTERIAN CHURCH CHILDREN'S CENTER
FACILITY NUMBER: 191501334
VISIT DATE: 10/17/2024
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urgent care and had received medical attention. Director stated that there was no medical report provided to the facility by C1’s parent, however LPA did receive a copy of the ProCare conversation between parent and staff regarding the medical care. C1 returned to school the following school day. Director also stated that C1’s parent received a copy of the Unusual Incident Report (UIR) for their records. LPA consulted with Director about procedures with UIRs and injury reporting to parents, as well as keeping running records of any disclosures about marks or injuries they observe on the children when coming to school.

No citations have been issued at this time.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Director, Saskia (Sacha) Lord.


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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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