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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910496
Report Date: 03/28/2024
Date Signed: 03/28/2024 12:27:04 PM


Document Has Been Signed on 03/28/2024 12:27 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
CCLD Regional Office, 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: 56DATE:
03/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Elizabeth ZaragozaTIME COMPLETED:
12:35 PM
NARRATIVE
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On March 28, 2023, at 11:33 AM, Licensing Program Analysts (LPAs) Cindy Hamilton and Kelly Gerth, arrived at the facility to continue a case management visit on an Unusual Incident Report (UIR) dated March 13, 2024. During the inspection, LPAs toured the facility, took census and met with Director Elizabeth Zaragoza.

The reported incident occurred on unknown date, Director was notified of the alleged incident on 03/13/2024, then reported it to Community Care Licensing and began an internal investigation. The information that was reported alleged that staff #1 (S1) pulled a child’s ear while in care. A review of the staff record was conducted by LPA Hamilton and LPA noted that CCC conducted their own investigation; however they were unable to determine whether the incident did occur. Futher information was revealed that S1 yelled at children and a “support plan” was completed. LPAs reviewed the support plan prepared by facility for S1 and it was confirmed via interviews and records review that S1 was disciplined for yelling at children.

Based on interviews and record review, the facility is being cited for Title 22, Division 12, Chapter 1, Article 06, Section:101223(a)(1) Personal Rights, pertaining to the reported incident.

An exit interview was conducted, a copy of this report, appeal rights and a Notice of Site visit was issued to Director Elizabeth Zaragoza. Director was reminded that the notice of site visit must remain posted for 30 consecutive days.

SUPERVISOR'S NAME: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Cindy HamiltonTELEPHONE: (951) 295-2190
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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 2


Document Has Been Signed on 03/28/2024 12:27 PM - It Cannot Be Edited

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: SAN JACINTO HEADSTART/STATE PRESCHOOL
FACILITY NUMBER: 330910496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2024
Section Cited
CCR
101223(a)(1)

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101223(a)(1) Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement has not been met as evidenced by:
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Director stated that a support plan has been created by facility and RCOE for S1 to receive ongoing training on personal rights, mandated reporter, health and wellness activities and interpersonal training. Director will provide proof to LPA via email that support plan has been initiated with S1 and training has began on or before the POC due date.
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Based on interviews and document review S1 was observed yeling at child(ren) which poses a potential health, safety and/or personal rights risk to children in care.
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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: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Cindy HamiltonTELEPHONE: (951) 295-2190
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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