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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830640
Report Date: 03/02/2022
Date Signed: 03/02/2022 02:34:27 PM


Document Has Been Signed on 03/02/2022 02:34 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 ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:KIDD STREET PRESCHOOL OF RIVERSIDEFACILITY NUMBER:
334830640
ADMINISTRATOR:MARIA TEELFACILITY TYPE:
840
ADDRESS:10250 KIDD STREETTELEPHONE:
(951) 688-4242
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:47CENSUS: 26DATE:
03/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Lucy Casillas; Assistant DirectorTIME COMPLETED:
02:45 PM
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A case management 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 02/17/2022. It indicates that on 02/15/2022 child #1 was playing, titling the chair back despite staff telling him not to. The chair started to fall backwards and the child extended his hand to break the fall. One staff was present at the time of the incident.

Facility records were reviewed and staff and child #1 were interviewed. Based on information gathered, the facility acted appropriately and no violations have been identified. Staff provided the child with ice upon his request but did not observe any swelling or discoloration. The incident happened on Tuesday 02/15/2022 and the child was taken to the hospital by his mother. The child returned to the facility on 02/16/2022.

An exit interview was conducted and a copy of this report was provided to facility staff.

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Karrene PhillipsTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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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