330908837-9-18-2019-10-CC-AWIN-BG5TMA-20190918145049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 330908837
Report Date: 09/18/2019
Date Signed: 09/18/2019 02:50:56 PM

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:	HEMET HEADSTART/STATE PRESCHOOL-LITTLE LAKE SOUTH		FACILITY NUMBER:	330908837
ADMINISTRATOR:	ALICE CHUNG		FACILITY TYPE:	850
ADDRESS:	26091 MERIDIAN STREET		TELEPHONE:	(951) 765-1668
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	54	CENSUS: 40	DATE:	09/18/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Cinthia Gutierrez, Lead Teacher		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alaina Wilburn 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 September 11, 2019. It indicates that Child #1 was playing on the playground on August 28, 2019 at 9:45am, and while trying to get off the bus structure, Child #1 jumped off. During the jump, Child #1 landed on child's knees and elbows. (Confidential Report LIC811 included for reference.) Child #1 did not immediately display much concern, but Teacher observed a scratch on elbow, and a Band-Aid was applied.

LPA Wilburn toured the playground, and observed the bus to be age appropriate with proper cushioning. Facility records were reviewed for child #1. Later that evening, child complained of pain to elbow. Family transported child to emergency for follow up and x-rays. The evaluation determined child's elbow to be broken and a cast was applied to arm. Child #1 returned to school without restrictions., besides keeping cast dry and out of sand. Principal instructed Teachers to have alternative activities for child during this time. Child #1 was not present during today's visit, due to a follow up Doctors appointment.

Based on information gathered, the facility acted appropriately and no violations have been identified.

An exit interview was conducted and a copy of this report was provided to facility staff.

SUPERVISOR'S NAME: Telma Sandoval	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Alaina Wilburn	TELEPHONE: (951) 255-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019

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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