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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364841081
Report Date: 05/05/2021
Date Signed: 05/05/2021 02:00:00 PM

Document Has Been Signed on 05/05/2021 02:00 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:ABUNDANT PRESCHOOL OF LEARNINGFACILITY NUMBER:
364841081
ADMINISTRATOR:DOMINIGUE LUCIENFACILITY TYPE:
850
ADDRESS:10900 CIVIC CENTER DRIVETELEPHONE:
(909) 204-4514
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: 128TOTAL ENROLLED CHILDREN: 0CENSUS: 104DATE:
05/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Dominque Lucien/DirectorTIME COMPLETED:
01:47 PM
NARRATIVE
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On 5/5/2021 at 1:30 PM, Licensing Program Analyst (LPA) Patricia Berry conducted a tele-inspection visit, via Face Time, due to COVID-19 and DPH guidelines of social distancing. The purpose of the tele-inspection visit was to conduct a case management- incident investigation. LPA made contact with the director, toured facility and took a census. LPA spoke with director Dominique Lucien regarding an incident that occurred on 4/20/21. Director self reported to LPA that on 4/20, a child fell on the playground while climbing a rock structure. LPA viewed the camera footage and observed, the child climbed up the rock structure, as child reached the top of the structure child leaned to the right of the structure and child fell off to the side. LPA observed teacher coming around the corner as the child ran to the teacher and the teacher picking the child up and giving the child a hug.

According to interviews conducted the child ran to a teacher shaking. According to director she called parent immediately. Director stated staff did not assess the nature of the child's illness or injury. LPA has determined the fall to be an accident, however, staff failed to provide an assessment which prompted a delay in getting medical treatment for the child.



(Cont on 809C)
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2021
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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Document Has Been Signed on 05/05/2021 02:00 PM - It Cannot Be Edited


Created By: Patricia Berry On 05/05/2021 at 11:14 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: ABUNDANT PRESCHOOL OF LEARNING
FACILITY NUMBER: 364841081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2021
Section Cited
CCR
101226(c)

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Health-Related Services (c) The licensee shall obtain emergency medical treatment without specific instructions from the child's authorized representative ...

This requirement was not met as evidenced by
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Director conducted a staff meeting to inform staff of the process/assessment to be taken if a child is showing any signs and/or symptoms that are not normal. Director stated she will send a list of participants and topic to Community Care Licensing by 5/6/2021.
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Based on interviews conducted, it was revealed, facility did not provide appropriate assessment to child after the child fell from the play structure.
This is an immediate risk to the health and safety of children in care
POC was discussed with director.
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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:Patricia Berry
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2021


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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: ABUNDANT PRESCHOOL OF LEARNING
FACILITY NUMBER: 364841081
VISIT DATE: 05/05/2021
NARRATIVE
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See LIC 809D for deficiency cited.

Director submitted an Unusual Incident Report to the Unusual Incident Report email address.

LPA contacted the Director to review the report. This report will be sent via email to the provided email address with an attached read receipt. A copy of the LIC 9213- Notice of Site Visit, LIC 811 Confidential Names List, Acknowledgment of Receipt and Appeal Rights are sent via email along with the report. The read receipt will be used in lieu of the signature on the report.



LIC 9102-Technical Assistance also provided.


All reports shall be maintained for three years.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC809 (FAS) - (06/04)
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