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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911516
Report Date: 03/02/2022
Date Signed: 03/03/2022 09:02:39 AM

Document Has Been Signed on 03/03/2022 09:02 AM - It Cannot Be Edited

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:PSD/CHINO HEAD STARTFACILITY NUMBER:
360911516
ADMINISTRATOR:MARIA BRIONESFACILITY TYPE:
850
ADDRESS:5585 RIVERSIDE DRIVETELEPHONE:
(909) 627-0206
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 110TOTAL ENROLLED CHILDREN: 110CENSUS: 53DATE:
03/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Phyllis GonzalezTIME COMPLETED:
12:50 PM
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On this date and time, Licensing Program Analyst (LPA) Laura Mejorado conducted an unannounced case management inspection to follow-up on an Unusual Incident Report (UIR) submitted by the facility to the Riverside Child Care Regional Office on 2/15/22. During this inspection, LPA met with Acting Site Supervisor Phyllis Gonzalez and discussed the following:

It was reported that on 2/15/22, while playing outside with a ball a child slid and hit their head on the metal piece of a play structure (alligator seat) causing a cut on their eyebrow. A teacher immediately attended to the child and applied pressure to the cut while another staff called the parent. It was disclosed during interviews that parent asked staff not to call the ambulance. When parent arrived and saw the cut, they asked for the ambulance to be called, at this point the ambulance was called and arrived within five minutes. The ambulance arrived at the facility and evaluated the child stating the child will require stiches. The paramedic informed the parent the child can be taken by car; however, parent insisted the child be transported by ambulance. Later in the day the facility followed up with the parent and were informed the child receive stiches and will be out for a day. The child has since returned to the facility. Since the incident, the facility has taken extra precautions and covered the metal piece of the play structure with foam to prevent any future incident.

At this time based on information obtained during the inspection, as well as an inspection of the area where the reported incident occurred, there appears to be no violations of Title 22 Regulations at this time.

An exit interview was conducted, and a Notice of Site Visit was provided and must be posted for 30 days.

The signature below acknowledges this information was reviewed with Acting Site Supervisor Phyllis Gonzalez.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Laura Mejorado
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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