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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910781
Report Date: 05/30/2019
Date Signed: 05/30/2019 01:20:34 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/MISSION BELL ELEMENTARY STATE PRESCHOOLFACILITY NUMBER:
330910781
ADMINISTRATOR:KATRINA BROOKSFACILITY TYPE:
850
ADDRESS:4020 CONNING STREET RM. 5TELEPHONE:
(951) 360-2749
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY:24CENSUS: 22DATE:
05/30/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Teacher - Araceli CastroTIME COMPLETED:
01:25 PM
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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 05/29/2019.

The report received was regarding the incident that occurred on 05/28/2019 at about 9:30AM where a child had sustained an injury while on the school playground.

LPA Huynh was unable to conduct interviews since the child in question was absent and the morning facility staff who were present during the incident had already left for the day. LPA reviewed facility records.

Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the Director.

An exit interview was conducted, and a copy of this report was provided to facility staff.

SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: John HuynhTELEPHONE: (951) 529-2439
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2019
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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