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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830639
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:47:17 PM

Document Has Been Signed on 08/09/2023 03:47 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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KIDD STREET PRESCHOOL OF RIVERSIDEFACILITY NUMBER:
334830639
ADMINISTRATOR:MARIA TEELFACILITY TYPE:
850
ADDRESS:10250 KIDD STREETTELEPHONE:
(951) 688-4242
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 155TOTAL ENROLLED CHILDREN: 155CENSUS: 72DATE:
08/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Lucy CasillasTIME COMPLETED:
03:55 PM
NARRATIVE
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On the date and time listed above, 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 07/25/23. It indicates on 07/19/23 a child fell on their arm during outside activity and received first aid. Additionally, UIR indicates on 07/24/23 parent notified the facility that the child had a broken arm.

During tour of facility, LPA observed no hazards or holes on the outdoor surface area and 3-4 inches of cushioning material (wood chips) under high playground equipment.



LPA reviewed records and conducted three staff interview(s). Based on information gathered, the facility staff conducted a visual wellness check and provided first aid (ice). The facility also notified Licensing within the time frame set forth in Title 22 regulations. However, staff interviews disclosed that although they did not see any swelling or redness the child made statements of continued discomfort (pain in arm) throughout the day and facility did not contact the authorized representative in a timely manner per Title 22 regulations.

See LIC809D for deficiency cited.

An exit interview was conducted and a copy of this report, Notice of Site visit and appeal rights were provided to the Director, Lucia Casillas.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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Document Has Been Signed on 08/31/2023 08:10 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/30/2023 05:04 PM


Created By: Giselle Carbullido On 08/09/2023 at 03:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KIDD STREET PRESCHOOL OF RIVERSIDE
FACILITY NUMBER: 334830639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2023
Section Cited
CCR
101226(a)

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101226(a) Health-Related Services
(a) The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious ... scratch. The licensee shall obtain specific instructions ...on action to be taken. This requirement is not met as evidence by:
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Facility will submit proof of a staff meeting to review regulation 101226(a) including materials and signed staff attendance by POC due date 08/14/23.
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Based on interviews conducted the facility did not meet the section cited above in that the facility did not notify a child’s authorized representatives in a timely manner per Title 22 regulations. This poses a potential health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023


LIC809 (FAS) - (06/04)
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