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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501334
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:02:46 PM

Document Has Been Signed on 10/23/2024 03:02 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: 43DATE:
10/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Sacha Lord & Junli NguyenTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On October 23, 2024, at 1:30 pm Licensing Program Analyst (LPA) Carolyn Tuba conducted a case management inspection due to an incident that was self-reported, and an Unusual Incident Report (UIR) was submitted by the facility. The incident occurred on 10/17/2024 at approximately 3:35 pm outside on the preschool playground monkey bars. Covid risk assessment was conducted. LPA met with Assistant Director, Junli Nguyen initially and Saskia (Sacha) Lord arrived at the facility at 2:15 pm to facilitate the visit. LPA observed and took a census of 43 children with 5 staff during naptime.

The incident was reported to the Department within the required 24 hours of occurrence. The incident consisted with a child playing on the monkey bars on the preschool playground outside and the child sustained an injury which required medical attention.

During this investigation, LPA conducted interviews with Director, Assistant Director, and Child #1 (C1). Staff #1 (S1) will be interviewed over the phone on Monday, October 28, 2024. There were no other staff that had witnessed the incident. Child was going across the monkey bars alone.

Director stated that C1 was playing on the monkey bars and lost their grip and fell on the sand which resulted in a broken right arm. LPA took measurements and photos of the play equipment. The measurements from the monkey bars to the sand is 5 feet 2 inches and LPA measured the child’s arm lifted above their head down to their feet and the measurement was 3 feet 10 inches. LPA feels that the drop distance is appropriate. According to C1 they were going across the monkey bars and let go and fell on the ground hitting their arm on the sand area. Assistant Director provided LPA with the incident report given to the parent. The medical report was not available. Director provided LPA with the equipment diagram and shows that the equipment is for ages 2 to 12 years of age. The equipment is found to be age appropriate.
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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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: 10/23/2024
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The LPA observed that there is enough sand underneath however suggested that the sand be raked daily to avoid it from flattening. ProCare messaging was provided by the Director of the dialogue between parent of C1 and staff. First Aid was provided to C1 with an ice pack. Child returned to school on October 18, 2024, with no limitations and a soft sling cast.

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: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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