364809075-10-28-2022-09-CC-JGIE-CKMTQ5-20221028145523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364809075
Report Date: 10/28/2022
Date Signed: 10/28/2022 02:55:26 PM

Document Has Been Signed on 10/28/2022 02:55 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 CENTER		FACILITY NUMBER:	364809075
ADMINISTRATOR:	ALISA HOLTEGARRD		FACILITY TYPE:	850
ADDRESS:	960 W. BLOOMINGTON		TELEPHONE:	(909) 877-3399
CITY:	BLOOMINGTON	STATE: CA	ZIP CODE:	92316
CAPACITY: 72	TOTAL ENROLLED CHILDREN: 72	CENSUS: 14	DATE:	10/28/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Alisa Holtegarrd		TIME COMPLETED:	03:15 PM

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On 10/28/2022 at time listed above Licensing Program Analysts (LPA) Justin Giese conducted an unannounced visit to the facility to follow up on the submission of an Unusual Incident Report (UIR) that was received by the Regional Office on 10/05/2022 and processed on 10/10/2022. LPA Facility Director, Alisa Holtegarrd to discuss the purpose of the visit.

On October 05, 2022 Facility Staff self-reported an incident where a child in care sustained an injury on the school age playground. UIR stated that around 04:15pm a school age child was running on the playground, tripped on their own feet and bumped the crown of their head on a closed classroom door, resulting in a small laceration. UIR stated the fall was witnessed by facility staff as it had occurred. Staff immediately went to the child, escorted them to the front office and administered a compress to the cut. The parent/guardian of the child was contacted, and the child was picked up shortly after incident. UIR stated the parent/guardian contacted the facility the following day to inform that the child’s wound was tended too, and they would be returning to the facility with no restrictions.

At time of this visit, LPA toured the facility playground where the incident had occurred. In addition, LPA interviewed the child involved in this incident. Statements recorded form interviewing the Child revealed the fall and injury were accidental in nature. Child stated they were running across the playground, lost their balance and tripped on their own feet.

The incident was accidental in nature and there appear to be no violations of Title 22. Facility staff were present and quick to aid the child after the fall. Parents/guardians were notified immediately, and the Facility has fulfilled its reporting requirements to Licensing.

An exit interview was conducted, LPA provided the Director with a copy of this report and a notice of site visit on 10/28/2022. Notice of site visit must be displayed for the next 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

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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