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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600980
Report Date: 09/03/2019
Date Signed: 09/03/2019 09:41:14 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:MAAC PROJECT OCEANSIDE V HEAD STARTFACILITY NUMBER:
376600980
ADMINISTRATOR:GIBBS, SARAFACILITY TYPE:
850
ADDRESS:235 VIA PELICANOTELEPHONE:
(760) 433-7589
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:20CENSUS: 12DATE:
09/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Sara GibbsTIME COMPLETED:
09:50 AM
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A case management visit is being conducted by Licensing Program Analyst (LPA) James Wilkerson in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 08/14/19. It indicates that a child was on the playground running and tripped resulting in an injury to the child. A teacher stated that she was playing with the child and that the child started running and tripped. There were no other children around nor was there any play equipment. The child is too young to interview and is not verbal. Copies of "ouch" report, written staff statements and medical records were reviewed and obtained.

Based on information gathered, the facility acted appropriately and no violations have been identified.

An exit interview was conducted and a copy of this report was provided to Ms. Gibbs on this date.

A copy of this report must be made available to the public for three years.
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: James WilkersonTELEPHONE: (951) 218-7031
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2019
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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