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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334810701
Report Date: 09/13/2019
Date Signed: 09/13/2019 01:10:21 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: 61DATE:
09/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sarah YatesTIME COMPLETED:
09:30 AM
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LPA, Joanne Domingo arrived at the facility on a case management visit to follow-up on an unusual incident report submitted by the facility on 8/20/19. LPA Domingo met with Teacher, Graciela Betts to discuss the reported incident.

It is alleged that on 8/14/19, during outside play at approximately 11:45am, a child was walking on blocks in the patio area of the playground when the child slipped and fell hitting their head on a wood block. The child sustained a small cut on the forehead. First aid was administered, the child was cleaned up and parent was notified. Parent picked up child but did not seek medical attention. The child returned to school the following day.
Based on the information obtained during the visit, there appeared to be no violations of Title 22 Regulations pertaining to the reported incident. The facility has discarded the wooden blocks. Children were reminded to play safe and not walk on toys.

An exit interview was held with Supervisor Education Specialist, Sarah Yates. A Notice of Site visit was issued, along with a copy of this report. This report shall be public record for three years.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Joanne DomingoTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019
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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