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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334811930
Report Date: 02/14/2020
Date Signed: 02/14/2020 11:22:24 AM

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:RSD-HARVEST VALLEY HEAD START AND STATE PRESCHOOLFACILITY NUMBER:
334811930
ADMINISTRATOR:VANESSA RODRIGUEZFACILITY TYPE:
850
ADDRESS:29955 WATSON ROADTELEPHONE:
(951) 928-2915
CITY:ROMOLANDSTATE: CAZIP CODE:
92585
CAPACITY:40CENSUS: 24DATE:
02/14/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Deisi Varela, Lead TeacherTIME COMPLETED:
11:30 AM
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On 02/14/2020 at 9:58 AM, Licensing Program Analysts (LPAs) Susan Brewer and James Wilkerson, arrived at the facility for the purpose of conducting case management visit in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 02/11/2020, for an incident that took place on 02/10/2020 with the afternoon class.

Facility records were reviewed and children's files. Staff #1 and staff #2 were interviewed. Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee. Additional possible witnesses are not available to interview at this time. LPAs will return at a later date to complete the follow-up on the incident reported.

An exit interview was conducted by LPA S.Brewer, and a copy of this report was reviewed and provided to facility Staff Teacher Deisi Varela.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Susan BrewerTELEPHONE: (951) 970-0343
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2020
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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