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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910780
Report Date: 12/09/2024
Date Signed: 12/09/2024 10:08:33 AM

Document Has Been Signed on 12/09/2024 10:08 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:JUSD/WEST ELEMENTARY PRESCHOOL/HEADSTARTFACILITY NUMBER:
330910780
ADMINISTRATOR/
DIRECTOR:
KATRINA BFACILITY TYPE:
850
ADDRESS:5671 42ND STTELEPHONE:
(951) 222-7850
CITY:JURUPASTATE: CAZIP CODE:
92509
CAPACITY: 46TOTAL ENROLLED CHILDREN: 46CENSUS: 28DATE:
12/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Katrina BrooksTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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A case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 22 November 2024. It indicates a child sustained an injury on the outside play structure.

LPAs reviewed records and conducted interviews. At 8:47 AM LPAs obtained photo of outdoor activity area where the incident happened. LPAs verified no hazards to the play structure and rubber matting is present for cushioning a fall. Additionally, record review identified the child wore shoes in accordance with facility clothing policy.

Based on information gathered, the facility acted appropriately, and no violations have been identified. Facility provided first aid, comfort, and contacted authorized representative for pick up and additional follow up care. Facility completed reporting requirements as required by CCR regulations for Unusual Incident Reports (submission of LIC624) to the California Department of Social Services.

A technical advisory was issued to review that safe, healthful, and comfortable accommodations to meet children's needs is provided per CCR Tittle 22 regulation: 101223(a)(2) See LIC9102TA.

An exit interview was conducted and Licensing Program Analysts (LPAs) Atherton and Carbullido provided the facility representative a copy of this report, appeal rights, and notice of site visit during today's visit.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Chase Atherton
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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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