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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334815618
Report Date: 06/20/2022
Date Signed: 06/20/2022 03:18:46 PM


Document Has Been Signed on 06/20/2022 03:18 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: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: 0DATE:
06/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Rosie Navarro TIME COMPLETED:
03:28 PM
NARRATIVE
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On June 20, 2022 at 3:01 PM, Licensing Program Analyst (LPA) Anastasia Flores arrived and met with Secretary for Principal, Rosie Navarro, in regard to an incident that occurred on 04/27/22. During inspection on 05/20/22, LPA Flores conducted interviews with S1 and S2. LPA was informed that S3 was required to take additional trainings due to conducting an inappropriate hold on child while in care.

Based on interviews and records reviewed the licensee is being cited for 101223(a)(3) Personal Rights. This poses a potential health and safety risk to children in care. Staff #3 conducted a prone restraint alone with a child on at least one occasion, resulting in the child being injured.

A copy of this report, 809D, appeal rights and LIC811 were explained and provided to facility representative at time of visit.

SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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Document Has Been Signed on 06/20/2022 03:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SCHOOL
FACILITY NUMBER: 334815618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2022
Section Cited

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101223(a)3) Personal Rights; the licensee shall ensure that each child is accorded the following personal rights: to be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
this was not met as evidenced by...
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Based on interviews with Site Principal, records review child #1 was injured while in a manual restraint by staff #3. This poses a potential risk to children in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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