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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846174
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:34:27 PM

Document Has Been Signed on 12/07/2023 03:34 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:FAIRYTALE CASTLE PRESCHOOLFACILITY NUMBER:
364846174
ADMINISTRATOR:DIANNE TALENSFACILITY TYPE:
850
ADDRESS:710 EAST FOOTHILL BLVDTELEPHONE:
(626) 567-5678
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 116TOTAL ENROLLED CHILDREN: 116CENSUS: DATE:
12/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Dianne Talens/directorTIME COMPLETED:
03:00 PM
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On 12/7/2023 at 11:40 am, Licensing Program Analyst (LPA) Patricia Berry conducted a case management visit in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 11/17/2023.

Staff was interviewed.

Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee.

An exit interview was conducted and a copy of this report was provided to facility staff, appeal right and notice of site visit issued.

Notice of site visit must be posted for 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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