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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364809075
Report Date: 09/12/2022
Date Signed: 09/12/2022 03:14:37 PM

Document Has Been Signed on 09/12/2022 03:14 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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
364809075
ADMINISTRATOR:ALISA HOLTEGARRDFACILITY TYPE:
850
ADDRESS:960 W. BLOOMINGTONTELEPHONE:
(909) 877-3399
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 104TOTAL ENROLLED CHILDREN: 104CENSUS: 33DATE:
09/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Alisa HoltegarrdTIME COMPLETED:
03:20 PM
NARRATIVE
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On 09/12/2022 at time listed above Licensing Program Analyst (LPA) Justin Giese made an unannounced visit to the Facility for another purpose. LPA met with Facility Director, Alisa Holtegarrd.

Based on observations, records review and interviews conducted for a visit on 08/05/2022, LPA discovered the facility had knowledge of an unusual incident regarding a child sustaining a significant injury while in care and failed to report it to Licensing in an adequate time frame.

The facility was found to be in violation of the following Title 22 regulations: Reporting Requirements This is a Potential risk to the health and safety of children in care.

See LIC809D for Type B Deficiency


An exit interview was conducted with Facility Director


A NOTICE OF SITE VISIT WAS ISSUED AND LPA VERIFIED THAT IT WAS POSTED IN A PROMINENT LOCATION AT THE FACILITY BEFORE LEAVING. THE DIRECTOR UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS

Appeal rights were provided and discussed. A copy of this report was given to the Director on this date and must be made available to the public upon request for the next 3 years.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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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Document Has Been Signed on 09/12/2022 03:14 PM - It Cannot Be Edited


Created By: Justin Giese On 09/12/2022 at 03:03 PM
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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 364809075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2022
Section Cited
CCR
101212(d)(1)(b)

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Reporting Requirements – (d)Upon the occurrence… a report shall be made to the Department… within the Department's next working day… (1) Events reported shall include… (b) Any injury to any child that requires medical treatment.
This requirement has not been met as evidenced by:
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Facility Director understands the importance of reporting requirements and documentation of unusual incidents that occur in the facility. Facility Director will conduct training with staff and members of management on proper procedures for self-reporting and documenting unusual incidents that occur at the facility and the
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Based on interviews conducted with staff on 08/05/2022, LPA discovered the facility had knowledge of an unusual incident which occurred on 08/04/22 regarding a child sustaining an injury while in care and did not report it to licensing. This poses a potential risk to the health and safety of children in care.
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proper time frame they must be reported to licensing. Documentation of training/proof of correction will need to be submitted to LPA on or before the date of correction, 09/26/2022

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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:Gilbert Sena
LICENSING EVALUATOR NAME:Justin Giese
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


LIC809 (FAS) - (06/04)
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