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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843408
Report Date: 05/03/2022
Date Signed: 05/03/2022 09:41:44 AM

Document Has Been Signed on 05/03/2022 09:41 AM - 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:NOAH'S ARK 4 KIDS CHILD CARE CENTERFACILITY NUMBER:
364843408
ADMINISTRATOR:TAMMY MURPHYFACILITY TYPE:
830
ADDRESS:27061 BASELINETELEPHONE:
(951) 662-0943
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4TOTAL ENROLLED CHILDREN: 4CENSUS: 3DATE:
05/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tammy Murphy, LicenseeTIME COMPLETED:
09:45 AM
NARRATIVE
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On 05/03/2022 at 8:30AM, 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 04/28/2022. It indicates that while staff was assisting a child, another child exited the building and was found one minute later.

Facility records were reviewed, and staff interviews were conducted with the Licensee and Staff. Interviews and records revealed a child was able to exit the front door of the facility without supervision. Based on the information gathered, the following violations have been identified:



CCR 101229(a)(1)
Responsibility for Providing Care and Supervision (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Division 12. An immediate $500.00 civil penalty has been issued.

An exit interview was conducted, appeal rights discussed, and a copy of this report and NOS was provided to facility staff.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
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 05/03/2022 09:41 AM - It Cannot Be Edited


Created By: Giselle Carbullido On 05/03/2022 at 08:54 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: NOAH'S ARK 4 KIDS CHILD CARE CENTER
FACILITY NUMBER: 364843408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2022
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Responsibility for Providing Care and Supervision (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement is not met as evidenced by:
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Licensee agrees to provide this report, cited deficiency and other pertinent documents issued by the department to the parent(s) of children in care within 24 hours or the next time in care; this includes all newly enrolled children over the next 12 months. Licensee agrees to submit proof of the signed acknowledgment(s) (LIC9224) to
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Based on LPA’s record review, staff interview and facility’s self-report the facility did not maintain supervision of all children which resulted in a child exiting the front entrance door, crossing the porch and steps, and walking towards the entry gate. This is an immediate risk to the health and safety of children in care . A civil penalty has been assessed.
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the department by May 4, 2022. Licensee also agrees to provide in-service training to staff regarding Responsibility for Providing Care and Supervision and will submit proof of training to the Department by the close of business day, 5/4/2022. **AN IMMEDIATE CIVIL PENALTY HAS BEEN ASSESSED FOR $500.00.***

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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:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022


LIC809 (FAS) - (06/04)
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