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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842393
Report Date: 07/21/2021
Date Signed: 07/21/2021 11:40:04 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: 7DATE:
07/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Babara Esther, DirectorTIME COMPLETED:
11:45 AM
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On 07/21/21 at 10:35am, 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 07/14/21. It indicates an injury was found on child while in care.

Facility records were reviewed, and interviews were conducted with Director and Staff. 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 Department within 24 hours via submission of the Unusual Incident Report- LIC624 and notifying the parent of injury and follow up telephone call with parent.

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: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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