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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364801117
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:08:58 PM


Document Has Been Signed on 04/28/2022 02:08 PM - 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: 22DATE:
04/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Taiesha MitchellTIME COMPLETED:
02:20 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
On 04/28/2022 Licensing Program Analysts (LPA) Justin Giese conducted a subsequent 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. LPA met with Site Supervisor, Taiesha Mitchell to discuss the purpose of the visit.

Site 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 returned to the facility reported what the Child had stated to Facility Site Supervisor.

On 04/07/2022 LPA made one unannounced visit to the facility for the purpose of following up on the receipt of the UIR. During this visit LPA toured the facility, reviewed/collected documents and conducted interviews facility staff. Between the dates of 04/07/2022 and 04/28/2022 LPA conducted additional interviews with all pertinent individuals identified in the UIR. Based on statements from individuals Interviewed and information obtained during this time period, LPA recorded conflicting information from what was stated in the UIR. Therefore, due to conflicting information available, the reported incident may have happened, or is valid. LPA was unable to corroborate if the alleged incident did or did not occur.

Continued on LIC809C
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 364801117
VISIT DATE: 04/28/2022
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
26
27
28
29
30
31
32
Based on LPA's observations, interviews and information obtained, there appeared to be no regulatory violations pertaining to the reported incident. Additionally, LPA did not observe any violations during their unannounced visits to the facility. The facility was found to be in compliance and has fulfilled their reporting requirements pertaining to the submission of incident reports.

No deficiencies cited during this visit

An exit interview was conducted, LPA reviewed this report with Site Supervisor, Taiesha Mitchell. A copy of this report and notice of site visit were provided. Notice of site visit must be displayed in a prominent location for the next 30 days.

A copy of this report must be made available for the next three years.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2