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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 01:11:06 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:
10:00 AM
MET WITH:Sarah YatesTIME COMPLETED:
10:30 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 Joanne Domingo met with Teacher, Brenda Guzman to discuss the reported incident.
It is alleged that during outside play on 8/14/19 at approximately 11:45am a child who was playing in the concrete area near the tables was hopping/jumping around in place. The child lost their balance and had accidentally bumped into another child who was nearby. The two children bumped their heads. The child who was jumping around sustained a bump on the left side of their forehead. The other child did not sustain a bump or a bruise and continued to play. An ice pack was given to the child and comforted. Staff notified parent and continued to monitor the child throughout the day. 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.

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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