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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830639
Report Date: 09/07/2021
Date Signed: 09/07/2021 11:28:56 AM

Document Has Been Signed on 09/07/2021 11:28 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KIDD STREET PRESCHOOL OF RIVERSIDEFACILITY NUMBER:
334830639
ADMINISTRATOR:MELISSA HAWTHORNEFACILITY TYPE:
850
ADDRESS:10250 KIDD STREETTELEPHONE:
(951) 688-4242
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 155TOTAL ENROLLED CHILDREN: 0CENSUS: 56DATE:
09/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Jeni Gonzalez-Executive DirectorTIME COMPLETED:
11:30 AM
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On 9/7/2021 at 10:15 AM, Licensing Program Analyst (LPA) Andrea Taylor conducted an inspection visit with Executive Director, Jeni Gonzalez.

A case management inspection is being conducted in response to the receipt of a self-reported unusual
incident report (UIR) from the facility. The UIR was received by the licensing agency on 8/27/21.
The incident occurred on 8/20/21. It was reported a child slipped and hit the bar on the stairs going up to climbing structure.

LPA obtained records regarding incident. LPA interviewed all pertinent persons. It was disclosed child's foot slipped on the bar going up to the play structure. Staff stated they were supervising the children at the time child slipped. The child confirmed this is what occurred.

LPA Taylor observed a non-slip material applied to the stair bars. The Executive Director stated this was add since the incident to prevent this from happening again. Staff stated the structure has been on the play yard at least two years and no children have ever slipped before.

An exit interview was conducted.
The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days.
Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent
to the door.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Andrea Taylor
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2021
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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