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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334815618
Report Date: 05/20/2022
Date Signed: 05/20/2022 10:21:29 AM


Document Has Been Signed on 05/20/2022 10:21 AM - 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:VVUSD-MANUEL L. REAL ELEMENTARY SCHOOLFACILITY NUMBER:
334815618
ADMINISTRATOR:ANDREA RODICH-VITECKFACILITY TYPE:
850
ADDRESS:19150 CLARK STREETTELEPHONE:
(951) 940-6190
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY:24CENSUS: 9DATE:
05/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Ricardo RinconTIME COMPLETED:
10:30 AM
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On May 20, 2022 at 8:44 AM, Licensing Program Analyst (LPA) Anastasia Flores arrived and met with, Site Principal, Ricardo Rincon. LPA informed Mr. Rincon purpose of the visit was to conduct a case management visit follow up on an unusual incident report submitted to the department on 05/05/22. LPA interviewed staff, reviewed children’s records and requested pertinent documents; staff contact information, Child #1's, C1’s Individual Education Plan, staff #1 (S1) personnel training records, copy of letter of reprimand given in regard to the incident on 04/27/22.

LPA conducted a census and a tour of the facility. No Deficiencies cited at this time due to further investigation needed.

An exit interview was held with Facility Representative, Andrea Rodich-Vitek. A Notice of Site visit was issued, along with a copy of this report and LIC811 (confidential names).

SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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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