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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364801956
Report Date: 10/07/2021
Date Signed: 10/07/2021 11:22:38 AM

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:SBCSS ANNA BORBA STATE PRESCHOOLFACILITY NUMBER:
364801956
ADMINISTRATOR:JENELYN PEREZFACILITY TYPE:
850
ADDRESS:4980 RIVERSIDE DRIVETELEPHONE:
(909) 464-2695
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:24CENSUS: 13DATE:
10/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jenelyn Perez/State Preschool TeacherTIME COMPLETED:
11:35 AM
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Licensing Program Analyst's (LPA's) Patricia Berry and Sumayya Habeebulla conducted a case management visit to inspect the new play structure. LPA's observed the play structure to meet Title 22 regulations. LPA's observed cushioning to absorb falls under the playground equipment.

Exit interview conducted with Lead teacher and report given.

LPA’s observed lead teacher post Notice of Site Visit

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Patricia BerryTELEPHONE: (951) 782-4952
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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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