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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910580
Report Date: 03/09/2020
Date Signed: 03/09/2020 11:24:28 AM

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:LAKE ELSINORE MACHADO STATE PRESCHOOL/HEAD STARTFACILITY NUMBER:
330910580
ADMINISTRATOR:FRIEDA BRANDSFACILITY TYPE:
850
ADDRESS:15150 JOY STREETTELEPHONE:
(951) 253-7662
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:82CENSUS: 56DATE:
03/09/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sarah YatesTIME COMPLETED:
10:45 AM
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LPA, Joanne Domingo arrived at the facility on a case management visit to follow-up on an unusual incident report submitted by the facility on 2/24/2020.
LPA Joanne Domingo met with Education Specialist Supervisor, Sarah Yates to discuss the reported incident. LPA conducted interview with the child as well.

It is alleged that on 2/20/2020, two children were riding the passenger tricycle when the driver of the tricycle suddenly stopped peddling and the tricycle came to a halt. The child who was sitting in the back cargo area of the tricycle bumped their head on the back of the tricycle frame when the tricycle stopped. The child cried out and Staff #1 responded. Staff #1 applied an ice pack but did not observe any broken skin or injuries. The child received a bump on the back of their head behind their left ear. The child's parent was called as a precaution. The child was given an ice-pack and assessed for any injuries. The child returned to school the following Tuesday.

Based on the information obtained during the visit, there appeared to be no violations of Title 22 Regulations pertaining to the reported incident.

An exit interview was held with Education Specialist Supervisor, Sarah Yates. A Notice of Site visit was issued, along with a copy of this report. This report shall be public record for three years.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Joanne DomingoTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2020
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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