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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842315
Report Date: 07/18/2024
Date Signed: 07/18/2024 12:16:35 PM

Document Has Been Signed on 07/18/2024 12:16 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:LEARNING EXPERIENCE, THEFACILITY NUMBER:
334842315
ADMINISTRATOR/
DIRECTOR:		ELENA BOLINGFACILITY TYPE:
850
ADDRESS:12754 LIMONITE AVENUETELEPHONE:
(951) 817-8817
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 193TOTAL ENROLLED CHILDREN: 193CENSUS: 88DATE:
07/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Elena Boling, DirectorTIME VISIT/
INSPECTION COMPLETED:
12:21 PM
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On July 18, 2024, Licensing Program Analysts (LPAs) Elyse Jones and Taityana Benson arrived at the facility to conduct a Case Management inspection is being conducted in response to the receipt of an Unusual Incident Report (UIR) from the facility. The UIR was received by the licensing agency on July 8, 2024. It indicates C1 drank from another child’s cup which led to him/her having an allergic reaction. It was disclosed staff observed C1 drinking from the cup but did not know if the cup belonged to him/her, therefore, staff allowed C1 to continue to drink from the cup. After staff realized the cup did not belong to C1, they also realized there was milk in the cup. Shortly after C1 drank the milk, he/she started rubbing their eyes and had a runny nose. Authorized Representative(s) were contacted to inform them of the incident and explained C1 would be monitored. The symptoms gradually worsened and the facility contacted the Authorized Representative (s) to pick up C1. During a follow up call with the Authorized Representative (s) the facility was informed C1 was given medication to assist in controlling the symptoms of the allergic reaction from the milk.

Facility records were reviewed including medical documentation which state C1 has a known food allergy to dairy. Medical intervention is on site. Based on the information gathered the following violation has been identified: 101221 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: (A) Dietary restrictions and allergies.

See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: LEARNING EXPERIENCE, THE
FACILITY NUMBER: 334842315
VISIT DATE: 07/18/2024
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LPA informed Elena Boling, Director that this report dated 7-18-2024 documents one Type A citation which shall be posted for 30 consecutive days as there was an immediate risk to the Health, Safety, or Personal Rights of children in care. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) was provided to facility during this inspection. The LIC 9224/Type A citation must be provided to parents/guardian of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for the verification.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Elena Boling, Director.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/18/2024 12:16 PM - It Cannot Be Edited


Created By: Elyse Jones On 07/18/2024 at 11:12 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LEARNING EXPERIENCE, THE
FACILITY NUMBER: 334842315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
07/19/2024
Section Cited
CCR
101221(b)(8)(A)

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101221 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: (A) Dietary restrictions and allergies.
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The facility agrees to submit a written statement to explain how the facility plans to ensure another incident like this does not occur and how the facility plans to remain in compliance with all regulations. The statement is due on or by POC due date of 7-19-2024.
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Based on the interview and record review, the Licensee did not meet the above regulation which poses an immediate Health, Safety & Personal Rights risk to the children in care. The UIR stated C1 drank out of another which led to C1 having an allergic reaction.
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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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
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