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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844025
Report Date: 09/12/2019
Date Signed: 09/12/2019 10:36:55 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:LEUSD DONALD GRAHAM STATE PRESCHOOLFACILITY NUMBER:
334844025
ADMINISTRATOR:BRANDS, FRIEDAFACILITY TYPE:
850
ADDRESS:35450 FREDERICK STREETTELEPHONE:
(951) 678-8450
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:24CENSUS: 20DATE:
09/12/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer MunizTIME COMPLETED:
10:30 AM
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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 8/30/19. The incident occurred on 8/28/19. At the time of visit, the class was outside for morning play. LPA Domingo and met with Teacher, Jennifer Muniz to discuss the reported incident.

It is alleged that on or about 8/28/19, a parent had noticed marks on their child's ears at pick up time approximately 12:00pm. The parent immediately returned to the classroom and spoke with teacher, Ms. Muniz and a report was filed. Based on the information obtained of the Child #1's activities on the day of the incident there appeared to be no violations of Title 22 Regulations pertaining to the reported incident. It was disclosed that Child #2 no longer attends the facility.

An exit interview was held with Teacher, Jennifer Muniz. 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: 09/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2019
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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