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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910921
Report Date: 10/04/2022
Date Signed: 10/04/2022 12:47:05 PM


Document Has Been Signed on 10/04/2022 12:47 PM - 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 STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:DSUSD/VAN BUREN ECE CENTERFACILITY NUMBER:
330910921
ADMINISTRATOR:JAY RALLIONFACILITY TYPE:
850
ADDRESS:47-733 VAN BUREN STREETTELEPHONE:
(760) 771-8675
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY:60CENSUS: 13DATE:
10/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Tracy LeeTIME COMPLETED:
12:51 PM
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Licensing Program Analyst (LPA) Jeanette Sanchez arrived at the facility to conduct a case management visit regarding an Unusual Incident Report (UIR) received on 8/30/22

LPA obtained roster and conducted interviews. Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided.

Exit interview conducted and report was reviewed with the facility representative Tracy Lee. Appeal rights were also provided and discussed this date.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Stephanie HudakTELEPHONE: (951) 320-2021
LICENSING EVALUATOR NAME: Jeanette SanchezTELEPHONE: (951) 255-4577
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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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