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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700650
Report Date: 11/14/2019
Date Signed: 11/14/2019 11:06:09 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 - FALLBROOK HEAD START - INFANTFACILITY NUMBER:
376700650
ADMINISTRATOR:M'LINDA ROSOLFACILITY TYPE:
830
ADDRESS:405 WEST FALLBROOK STREETTELEPHONE:
(760) 723-4189
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:12CENSUS: 13DATE:
11/14/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Laura Travis/Lead TeacherTIME COMPLETED:
11:10 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 11/04/19. It indicates that a child had ran outside to the infant playground and the infant teachers did not notice. There was a preschool teacher who was outside with her class and noticed the child exiting his/her classroom and went to the child and took the child back inside the classroom. Although the child left the classroom unnoticed by his/her teachers, the child was never left alone without any staff supervision as a preschool teacher had visual supervision on the child while he/she was outside for a very brief period (seconds, per staff). The child is non verbal.

Based on information gathered, the facility acted appropriately and no violations have been identified, as the child was not left without any supervision during this incident.

An exit interview was conducted and a copy of this report was provided to facility staff.
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: James WilkersonTELEPHONE: (951) 218-7031
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
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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