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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334810701
Report Date: 10/24/2019
Date Signed: 10/24/2019 01:19:01 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:LAKE ELSINORE USD HEAD START JEANNETTE ELLIS CTR.FACILITY NUMBER:
334810701
ADMINISTRATOR:FRIEDA BRANDSFACILITY TYPE:
850
ADDRESS:411 W. HEALD STREETTELEPHONE:
(951) 245-4794
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:81CENSUS: 57DATE:
10/24/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sarah YatesTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Joanne Domingo arrived at the facility to conduct a Case Management visit in response to the receipt of an unusual incident report (UIR) from the facility. LPA, Domingo met with Education Specialist Supervisor, Sarah Yates, to discuss the purpose of the visit, toured the facility and conducted census. The UIR was reported to the Duty Officer on 10/17/19. It indicates that on 10/17/19, during afternoon pick up time, two siblings had left the classroom and exited the fenced play area onto the sidewalk along W. Heald Street unsupervised.

It was disclosed that the parent of the children had arrived to pick up their children when the children were met by their parent near the parent's car. The parents car was parked along the sidewalk of W. Heald Street. The children were alone. The parent took the children back up to the classroom to sign the children out and inform the staff where the children were found. This is a ZERO-TOLERANCE citation.

SEE LIC 809D FOR DEFICIENCIES CITED DURING THIS VISIT.

A NOTICE OF SITE VISIT WAS ISSUED AND IS TO BE POSTED IN A PROMINENT LOCATION AT THE FACILITY FOR THE NEXT 30 DAYS ALONG WITH A COPY OF ALL TYPE A DEFICIENCIES (LIC809D) CITED DURING THIS INSPECTION. UPON RECEIPT A COPY OF ALL TYPE A DEFICIENCIES CITED DURING THIS INSPECTION MUST ALSO BE IMMEDIATELY (within 24 hours of the child’s next day in care) GIVEN TO THE PARENTS/ GUARDIANS OF ALL CHILDREN ENROLLED IN THE CHILD CARE FACILITY AND ANY CHILDREN ENROLLED INTO THE CHILD CARE FACILITY OVER THE NEXT 12 MONTHS.

An exit interview was conducted, appeal rights discussed and provided along with a copy of form LIC 9224 (AB 633) and a copy of this report on this date.

A copy of this report must be made available to the public for 3 years.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Joanne DomingoTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: LAKE ELSINORE USD HEAD START JEANNETTE ELLIS CTR.
FACILITY NUMBER: 334810701
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2019
Section Cited

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RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time.
This requirement was not met as evidenced by: two children had walked
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out of the classroom and gated yard onto the sidewalk on Heald Street which poses an immediate Health and Safety risk to children in care.
This is a zero tolerance citation for Absence of Supervision.
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Copies of the RCOE Supervison Plan
as well as the facility's "Active Supervision" handout were provided to LPA Domingo during this visit. Licensee advised a Non-Compliance Meeting has been scheduled for 11/08/19 at 2:00pm.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Joanne DomingoTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2019
LIC809 (FAS) - (06/04)
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