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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360902919
Report Date: 10/01/2021
Date Signed: 10/01/2021 03:29:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:PSD/SAN BERNARDINO PARK & REC HEAD STARTFACILITY NUMBER:
360902919
ADMINISTRATOR:LISA SIMMONSFACILITY TYPE:
850
ADDRESS:2969 FLORES STREETTELEPHONE:
(909) 887-3349
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY:30CENSUS: 0DATE:
10/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH: Nelly Munoz-Rios, Lead teacherTIME COMPLETED:
03:54 PM
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Licensing Program Analysts (LPA) Lady King-Lewis met with Lead teacher Nelly Munoz-Rios and teacher assistant Evelyn Brenton for a Case Management Incident inspection involving an Incident Report dated 0/924/2021. The incident occurred on 09/23/2021. No children were present at this inspection.

Description of the incident: Child #1 was injured while in care

LPA toured the area of the incident took photo of the outdoor play area, observed center video for the day of the incident, received contact information for children present at the center on 09-23-21.

Further information needed.

An exit interview was conducted, a copy of this report was read and provided to Nelly Munoz-Rios on this date.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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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