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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842393
Report Date: 07/07/2021
Date Signed: 07/07/2021 11:09:46 AM

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: 9DATE:
07/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Barbara EstherTIME COMPLETED:
11:15 AM
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On 07/07/21 at 9:30am 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 07/01/2021. It indicates there was an inappropriate action between two children at the facility.

Facility records were reviewed, photos obtained, and staff interviews were conducted with Site Director, assigned Aide and Teachers. Based on information gathered, the facility acted appropriately, and no violations have been identified.

At this time the facility took appropriate action by completing self-reporting requirements as required for UIRS: Notifying the Duty Officer within 24 hours and submitting the LIC624 to the Department of Social Services; utilizing direct observation procedures for supervision and communicating with Parent/Guardian.

There are no deficiencies cited. An exit interview was conducted, Notice of Site Visit issued, and a copy of this report was provided to the Licensee.

A copy of this report must be made available to the public upon request for 3 years.

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

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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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