<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910496
Report Date: 03/27/2024
Date Signed: 03/27/2024 03:27:56 PM


Document Has Been Signed on 03/27/2024 03:27 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:SAN JACINTO HEADSTART/STATE PRESCHOOLFACILITY NUMBER:
330910496
ADMINISTRATOR:ZARAGOZA, ELIZABETHFACILITY TYPE:
850
ADDRESS:257 GRAND ARMYTELEPHONE:
(951) 654-1531
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY:82CENSUS: 48DATE:
03/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Elizabeth Zaragoza-Director TIME COMPLETED:
03:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On March 27, 2024, at 135 pm Licensing Program Analysts (LPAs), Cindy Hamilton and Kelly Gerth conducted a Case Management visit at San Jacinto USD Head Start Preschool (CCC) to follow up on Unusual Incident Report (UIR) that was submitted to Licensing by the facility on March 13, 2024. LPAs met with the Director, Elizabeth Zaragoza, to discuss the incident. During the visit the LPA’s conducted interviews with staff and obtained pertinent documentation.

Due to the need to gather additional information, LPA’s will return to the CCC at a later date.

An exit interview was conducted, and a copy of this report, appeal rights and notice of site visit was provided to the Director.

A copy of this report must be made available to the public, at the facility site, for 3 years.
SUPERVISOR'S NAME: Carlos MartinezTELEPHONE: (951) 805-5739
LICENSING EVALUATOR NAME: Kelly GerthTELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1