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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364801117
Report Date: 04/07/2022
Date Signed: 04/07/2022 10:20:57 AM


Document Has Been Signed on 04/07/2022 10:20 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/BOYS & GIRLS CLUB HEAD START CENTERFACILITY NUMBER:
364801117
ADMINISTRATOR:HARRIET JAMESFACILITY TYPE:
850
ADDRESS:1180 W. 9TH STREETTELEPHONE:
(909) 381-4294
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92411
CAPACITY:95CENSUS: 29DATE:
04/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Taiesha MitchellTIME COMPLETED:
10:25 AM
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On 04/07/2022 Licensing Program Analysts (LPA) Justin Giese conducted an unannounced visit to the facility to follow up on the submission of an Unusual Incident Report (UIR) that was received by the Regional Office on 03/25/2022 and recorded on 03/29/2022. LPA met with Acting Site Supervisor, Taiesha Mitchell to discuss the purpose of the visit. LPA took census, reviewed records, toured the facility and conducted interviews.

Facility Supervisor contacted Licensing and self-reported an incident that had occurred at the facility on 03/24/2022. The UIR stated that on 03/24/2022 after school dismal, a child reported to their Parent/Guardian that a teacher had pulled their hair. The Parent/Guardian then reported what the Child had stated to Facility Site Supervisor.

Due to insufficient information available currently, LPA will return to the facility on a later date to conclude the investigation into this incident.

An exit interview was conducted, LPA Giese provided Site Supervisor with a copy of this report and a notice of site visit on 04/07/2022.

Notice of site visit must be displayed for the next 30 days.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
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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