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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364803437
Report Date: 08/23/2021
Date Signed: 08/23/2021 02:13:02 PM

Document Has Been Signed on 08/23/2021 02:13 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:FUSD/OAK PARKFACILITY NUMBER:
364803437
ADMINISTRATOR:DARCY WHITNEYFACILITY TYPE:
850
ADDRESS:14200 LIVE OAK AVENUETELEPHONE:
(909) 357-5696
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 24TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
08/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Darcy WhitneyTIME COMPLETED:
02:30 PM
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A case management visit 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 08/17/2021.

Facility records were reviewed and staff were interviewed. Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee.

An exit interview was conducted and a copy of this report was provided to the Director.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Taadhimeka Zeigler
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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