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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376300325
Report Date: 08/03/2023
Date Signed: 10/16/2023 12:22:32 PM

Document Has Been Signed on 10/16/2023 12:22 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:BUILDING KIDZ VISTAFACILITY NUMBER:
376300325
ADMINISTRATOR:SARAH DANIELFACILITY TYPE:
850
ADDRESS:777 TAYLOR STREETTELEPHONE:
(760) 945-9222
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 54TOTAL ENROLLED CHILDREN: 25CENSUS: DATE:
08/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Sarah DanielTIME COMPLETED:
02:15 PM
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This is an amended report to a visit conducted on the above date of 8/3/2023.

On October 16, 2023 at 12:00 pm, Licensing Program Analyst (LPA) Jessica Rubio arrived unannounced to the facility to amend the case management visit report for the unusual incident report received for an incident that occurred on 6/28/2023, reporting child (C1) slipping and hitting their chin on the playground slide and sustaining a cut that later required skin glue. LPA met with Director Sarah Daniel and conducted a tour and census of the facility. During the prior visit, LPA interviewed Director and C1. Interviews revealed there were 12 children on the playground at the time of the incident and a teacher (S1) and teacher's aide (S2) were providing supervision. An interview also revealed staff applied first aid and contacted C1's parent and C1 was picked up shortly after the incident. LPA observed the playground structure where the incident occurred. LPA observed the play structure stairs, platform and the slide to have some wear on the rubber coating. LPA also observed the manufacturer's sticker on the play structure to read that the structure is recommended for 5 - 12 year old children. C1 is less than five years old, however, LPA determined that the facility was not in violation of Title 22 Regulations.

An exit interview was conducted, a copy of this report, LIC 811 (Confidential Names List) and appeal rights were reviewed with and provided to Director Sarah Daniel. A notice of site visit will be provided and must remain posted for 30 days.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Jessica M Rubio
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
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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Document is an Amendment of Original Document on 10/02/2023 10:26 AM


Created By: Jessica M Rubio On 08/03/2023 at 01:33 PM
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
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: BUILDING KIDZ VISTA
FACILITY NUMBER: 376300325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed




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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:Pauline Beschorner
LICENSING EVALUATOR NAME:Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023


LIC809 (FAS) - (06/04)
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