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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842393
Report Date: 02/19/2020
Date Signed: 02/19/2020 02:01:43 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:PHILLIP M STOKOE HEAD STARTFACILITY NUMBER:
334842393
ADMINISTRATOR:BARBARA ESTHERFACILITY TYPE:
850
ADDRESS:4501 AMBS DRIVETELEPHONE:
(951) 826-4390
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:59CENSUS: 37DATE:
02/19/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Ana Cano, Community AssistantTIME COMPLETED:
02:15 PM
NARRATIVE
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On the date and time listed above, a case management inspection 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 02/14/2020. It indicates a child wandered out of their assigned classroom on 02/13/2020 and walked down to the office without supervision.

Facility records were reviewed, and staff interviews were conducted. LPA toured the facility and obtained photos.

Based on the information gathered, the following violations have been identified: Responsibility for Providing Care and Supervision CCR 101229(a)(1) per Title 22 regulations.

See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12.

An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to facility staff.

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2020
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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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: PHILLIP M STOKOE HEAD START
FACILITY NUMBER: 334842393
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2020
Section Cited

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Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation. This requirement was not met as evidenced by:
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Based upon LPA interviews and evidenced gathered,facility staff did not maintain or provide supervision to Child #1. This poses an immediate health and safety risk to children in care.
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Facility Director plans to conduct a staff meeting to review supervision within the program on 02/21/2020. Facility Director will submit documentation to LPA Carbullido on topics covered and the attendance record of program staff in attendance.

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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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2020
LIC809 (FAS) - (06/04)
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