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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910778
Report Date: 10/14/2021
Date Signed: 10/14/2021 12:06:31 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: 0DATE:
10/14/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Katrina BrooksTIME COMPLETED:
12:20 PM
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LPA Zeigler conducted a visit to the facility to inspect the newly installed playground. LPA met with Katrina Brooks. There were no children in care at the time of visit. A tour of the playground was conducted.

Upon review of the playground, it appears to be in compliance with Title 22 Regulations and meets the guidelines for safe play....101238.2 Outdoor Activity Space.


An exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Taadhimeka ZeiglerTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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