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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334816075
Report Date: 10/11/2019
Date Signed: 10/11/2019 12:24:37 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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:PVUSD-EARLY CHILDHOOD PROGRAMFACILITY NUMBER:
334816075
ADMINISTRATOR:MARIA SANTOSFACILITY TYPE:
850
ADDRESS:295 EAST CHANSLORWAYTELEPHONE:
(760) 922-8454
CITY:BLYTHESTATE: CAZIP CODE:
92225
CAPACITY:160CENSUS: 97DATE:
10/11/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Cindy Floyd, Program DirectorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst's (LPA's), Marlene Wong and Carlos Martinez, arrived to follow up on an Unusual Incident report that was submitted to Licensing by the facility on 09/20/19. LPA met with the Cindy Floyd, Program Director, to discuss incident.

According to Unusual Incident Report, and per information gathered, on 05/17/19, (2) Staff observed Staff #1 grab Child #1 from the upper arm and drag him onto the playground. According to witness statements provided, Staff #3 had just finished a speech session with the child, and was getting ready to take him back to join his classroom in the playground when Staff #1 approached her and yanked the child from her hand and consequently dragged him off. Staff #2 was out in the playground as well and observed the entire incident and provided a written statement detailing the entire incident.

During this visit, LPA Martinez verified that Staff #1 was disciplined, and was issued a verbal and written warning. In addition, LPA Martinez determined that Staff #1 violated Child #`'s Personal Rights, and issued a deficiency.



An exit interview was conducted, and a copy of this report was provided.

A copy of this report must be made available to the public, at the facility site, for 3 years.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Carlos MartinezTELEPHONE: (951) 295-2190
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2019
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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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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PVUSD-EARLY CHILDHOOD PROGRAM
FACILITY NUMBER: 334816075
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2019
Section Cited

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PERSONAL RIGHTS:

Each child shall be free from corporal or unusual punishment, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature. This requirement was not met as evidenced by: LPA confirmed that a Staff #1 mishandled
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Child #1, by grabbing him by the upper arm, and dragging him onto the playground. This is an immediate risk to the health & safety, or personal rights of 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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Carlos MartinezTELEPHONE: (951) 295-2190
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2019
LIC809 (FAS) - (06/04)
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