<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842863
Report Date: 09/18/2019
Date Signed: 09/18/2019 02:41:21 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:LAKE ELSINORE USD HEAD START LAKELAND VILLAGE SCHLFACILITY NUMBER:
334842863
ADMINISTRATOR:BRANDS, FRIEDAFACILITY TYPE:
850
ADDRESS:18730 GRAND AVENUETELEPHONE:
(951) 253-7400
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:20CENSUS: 17DATE:
09/18/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Nicole MurilloTIME COMPLETED:
02:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Joanne Domingo arrived at the facility on a case management visit to follow-up on an unusual incident report submitted by the facility on 8/21/19. At the time of visit, LPA toured the facility, took census, and met with Teacher, Nicole Murillo to discuss the reported incident. Ms. Murillo witnessed the incident as it took place and immediately rendered first aid.
It is alleged that on 8/20/19, during outside play, a child who was sitting on the picnic bench had decided to scoot back on the bench. The child proceeded to scoot back unaware that that was the end of the bench, fell backwards, landed on the concrete and hitting the back of their head on the concrete. The child sustained a bump to the back of their head. No cuts or scrapes. First aid and an ice pack were applied. Parent was notified however the child remained at school. The following day, the child return to school. Parent did not seek medical attention.
Based on the information obtained during the visit, there appeared to be no violations of Title 22 Regulations pertaining to the reported incident.

An exit interview was held with Teacher, Nicole Murillo. A Notice of Site visit was issued, along with a copy of this report. This report shall be public record for three years.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Joanne DomingoTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1