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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334811701
Report Date: 04/03/2024
Date Signed: 04/03/2024 01:56:02 PM


Document Has Been Signed on 04/03/2024 01:56 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:SJUSD-HYATT HEAD START STATE PRESCHOOLFACILITY NUMBER:
334811701
ADMINISTRATOR:ZARAGOZA, ELIZABETHFACILITY TYPE:
850
ADDRESS:400 E. SHAVERTELEPHONE:
(951) 487-0526
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY:108CENSUS: 76DATE:
04/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Elizabeth ZaragozaTIME COMPLETED:
01:00 PM
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On April 3, 2024 at 11:25 am Licensing Program Analyst (LPA) Cindy Hamilton and Licensing Program Manager (LPM) Carlos Martinez arrived at San Jacinto Unified School District Hyatt Head Start/State Preschool and met with Education Coordinator Kimberly Byers and Director Elizabeth Zaragoza to conduct a case management visit. This 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 03/18/2024. It indicates that a child fell off the play structure and broke their left arm.

Facility records were reviewed and staff was interviewed. Based on information gathered, the facility acted appropriately and no violations have been identified. The facility was operating within ratio as regulated by Title 22 and provided immediate aid to the child and parents were notified. A tour of the play structure was also conducted and LPA verified that the structure and toys were in good condition and operating order.

An exit interview was conducted and a copy of this report, appeal rights and Notice of Site Visit was provided to facility staff.

SUPERVISOR'S NAME: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Cindy HamiltonTELEPHONE: (951) 295-2190
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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