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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364801264
Report Date: 10/08/2019
Date Signed: 10/08/2019 01:09:59 PM

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/YUCAIPA HEAD STARTFACILITY NUMBER:
364801264
ADMINISTRATOR:DIANE MILIANFACILITY TYPE:
850
ADDRESS:12236 CALIFORNIA STREETTELEPHONE:
(909) 797-3585
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:66CENSUS: 32DATE:
10/08/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Diane MilianTIME COMPLETED:
01:15 PM
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On 10/8/19 at 12:30pm, Licensing Program Analyst (LPA) Destinee Hogue arrived at the facility to conduct a case management inspection in response to the receipt of an unusual incident report (UIR). The UIR was received by the Riverside Child Care Regional Office on 09/4/2019 via fax. Parents were notified of playground closure on 9/5/19 by a flyer that was placed at the entrance of the facility and throughout facility classrooms. Equipment construction was completed on Friday, September 20, 2019 and available for use Monday, September 23, 2019.

During this inspection the outdoor play equipment and cushioning surrounding play structure was inspected by LPA Hogue and observed to be in compliance with Title 22, Division 12, Chapter 1, Article 07 Physical Environment regulations.

LPA Hogue advised Site Supervisor Diane Milian to submit an updated LIC999 - Facility Sketch of outdoor activity space to the Department within the next 30 days (Due Date: 11/8/19). Pictures of playground were taken during this inspection and placed in facility file located at the Riverside Child Care Regional Office.

No deficiencies cited were cited during this inspection and a copy of this report was provided to Site Supervisor Diane Milian. Site Supervisor understands a copy of this report shall be kept on record for three years and provided to the public upon request.

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019
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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