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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910496
Report Date: 05/22/2024
Date Signed: 05/22/2024 12:38:45 PM

Document Has Been Signed on 05/22/2024 12:38 PM - It Cannot Be Edited

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:SAN JACINTO HEADSTART/STATE PRESCHOOLFACILITY NUMBER:
330910496
ADMINISTRATOR/
DIRECTOR:		ZARAGOZA, ELIZABETHFACILITY TYPE:
850
ADDRESS:257 GRAND ARMYTELEPHONE:
(951) 654-1531
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 82TOTAL ENROLLED CHILDREN: 68CENSUS: 54DATE:
05/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Elizabeth ZaragozaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On May 22, 2024, at 10:33 AM, Licensing Program Analyst (LPA) Cindy Hamilton arrived at the facility to conduct a case management visit on an Unusual Incident Report (UIR) dated May 10, 2024. During the inspection, LPA toured the facility, took census and met with Director Elizabeth Zaragoza.

The reported incident occurred on May 9, 2024, a child was on the playground playing with plastic stepping stones, slipped and hit chin on one of the plastic stepping stones resulting in a scrape on the chin and biting child’s tongue causing tongue to bleed. In addition, 9-1-1 was called and child transported to hospital via ambulance.

Facility records were reviewed and staff was interviewed. Based on information gathered, the facility acted appropriately and no violations have been identified. The facility called 9-1-1 because staff was unable to stop the bleeding and child was transported by ambulance at the parent/guardian’s request. The facility was operating within ratio as regulated by Title 22, provided proper supervision and immediate aid to the child and parents/guardians were notified. A tour of the playground was also conducted and LPA verified that the structures and toys were in good condition, age appropriate and in operating order.

An exit interview was conducted, a copy of this report, appeal rights and a Notice of Site visit was issued to Director Elizabeth Zaragoza. Director was reminded that the notice of site visit must remain posted for 30 consecutive days.

SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Cindy Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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