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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910781
Report Date: 10/14/2022
Date Signed: 10/14/2022 11:47:01 AM


Document Has Been Signed on 10/14/2022 11:47 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/MISSION BELL ELEMENTARY STATE PRESCHOOLFACILITY NUMBER:
330910781
ADMINISTRATOR:KATRINA BROOKSFACILITY TYPE:
850
ADDRESS:4020 CONNING STREET RM. 5TELEPHONE:
(951) 222-7850
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY:24CENSUS: 17DATE:
10/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Natalie Valle White Early Childhood SpecialistTIME COMPLETED:
11:45 AM
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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 10/04/2022.

Facility records were reviewed and staff interviews conducted. Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee.

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

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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