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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364840979
Report Date: 02/13/2025
Date Signed: 02/13/2025 12:28:48 PM

Document Has Been Signed on 02/13/2025 12:28 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:OMSD/SULTANA ELEMENTARY SCHOOLFACILITY NUMBER:
364840979
ADMINISTRATOR/
DIRECTOR:		ADRIANA MELGOZAFACILITY TYPE:
850
ADDRESS:1845 SOUTH SULTANA AVENUETELEPHONE:
(909) 459-1215
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 19DATE:
02/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Gianna Roca, program administrator TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On the date and time listed above, Licensing Program Analyst (LPA) Aman Lama arrived to the facility on another matter. LPA then opened a case management- Incident inspection with program administrator, Gianna Roca. LPA toured the facility, took census and conducted interviews.

The visit was in response to the receipt of an Unusual Incident Report (UIR), received by the Riverside Regional Office (RRO) on 02/07/2025. It was self-reported that a child shoved a bead up their nasal passage. Based on the information received, it is determined that there are no violations of Title 22 regulations.

Exit interview conducted with program administrator, Gianna Roca.

A copy of this report was provided.

The Notice of Site Visit must be posted for 30 consecutive days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Aman Lama
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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