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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910780
Report Date: 03/16/2022
Date Signed: 03/16/2022 09:16:02 AM


Document Has Been Signed on 03/16/2022 09:16 AM - 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 ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:JUSD/WEST ELEMENTARY PRESCHOOL/HEADSTARTFACILITY NUMBER:
330910780
ADMINISTRATOR:ROSA SANTOS-LEE, KATRINA BFACILITY TYPE:
850
ADDRESS:5671 42ND STTELEPHONE:
(951) 222-7850
CITY:JURUPASTATE: CAZIP CODE:
92509
CAPACITY:46CENSUS: 17DATE:
03/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Dee Bride, TeacherTIME COMPLETED:
09:25 AM
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On 03/16/22 at 8AM, a case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 03/04/22. It indicates bruises were sustained by child while in care.

Facility records were reviewed and interviews were conducted with staff and children. Staff interviews reported no injuries observed or occurring at the school with C1. Staff reported facility procedures are to put illness/injury incidents on ouch reports and report to parent when needed. Child 1 interview denied being hit by anyone or getting bruises from home or school. C2 interview reported they play ball with C1 and denied hitting, play fighting or falling down when playing together. Based on information gathered, the facility acted appropriately, and no violations have been identified.

At this time the facility took appropriate action by completing self-reporting requirements as required for Unusual Incidents (UIRS): Notifying the Department (CDSS) within 24 hours via submission of the Unusual Incident Report- LIC624, Cross reporting to Child Protective Services (CPS), conducting outdoor play observations, completing communication reports with Parent to discuss concern and other options (ie. Medical) for additional follow up.

There are no deficiencies cited. An exit interview was conducted, Notice of Site Visit issued, and a copy of this report was provided to the Teacher. A copy of this report must be made available to the public upon request for 3 years.

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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