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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700797
Report Date: 08/06/2019
Date Signed: 08/06/2019 09:57:09 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:MISSION HILLS CHURCH PRESCHOOLFACILITY NUMBER:
376700797
ADMINISTRATOR:WINKLER, ANGELAFACILITY TYPE:
850
ADDRESS:400 MISSION HILLS COURTTELEPHONE:
(760) 759-2164
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:100CENSUS: 35DATE:
08/06/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Louisa AguilarTIME COMPLETED:
10:05 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 06/24/19. It indicates that a child was on a play structure and slipped and fell injuring his/her arm. Interviews with staff/child(ren) disclosed that a teacher was with the child and couldn't prevent the accident from happening as it happened too quickly.

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. Aguilar on this date.
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: James WilkersonTELEPHONE: (951) 218-7031
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2019
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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