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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910778
Report Date: 05/03/2021
Date Signed: 05/03/2021 03:02:16 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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:JUSD/INA ARBUCKLE ELEMENTARYFACILITY NUMBER:
330910778
ADMINISTRATOR:KATRINA BROOKSFACILITY TYPE:
850
ADDRESS:3600 PACKARD STREETTELEPHONE:
(951) 222-7788
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY:48CENSUS: 5DATE:
05/03/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Katrina BrooksTIME COMPLETED:
08:00 AM
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Licensing Program Analyst (LPA) Taadhimeka Zeigler conducted a tele-inspection visit, via Face Time, due to COVID-19. The purpose of the tele-inspection visit is to follow up on a UIR reporting the re-opening of the facility and to provide Rapid Assistance Support during the COVID-19 Pandemic. LPA Zeigler met with Katrina Brooks, Director.

A virtual tour of the facility was conducted, via Face Time, which included the drop off and pick up process, the digital sign in process, classroom space/physical distancing, cleaning, meals, essential protective equipment and supplies, and additional health and safety measures that have been implemented by the facility.

LPA Zeigler and Ms. Brooks reviewed and discussed the self-assessment guide and the re-opening plan provided by the district. At this time, the facility appears to have the proper health and safety precautions in place to provide for a safe re-opening.

This report will be sent via email to the provided email address with an attached read receipt. A copy of LIC 9213 - Notice of Site Visit will be sent via email along with this report. The read receipt will be used in lieu of the signature on the report.

All reports shall be maintained for three years.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Taadhimeka ZeiglerTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
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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