334830641-2-5-2021-09-CC-ATAR-BXXURG-20210205144844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334830641
Report Date: 02/05/2021
Date Signed: 02/05/2021 02:49:11 PM

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 RIVERSIDE		FACILITY NUMBER:	334830641
ADMINISTRATOR:	MELISSA HAWTHORNE		FACILITY TYPE:	830
ADDRESS:	10250 KIDD STREET		TELEPHONE:	(951) 688-4242
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	28	CENSUS: 9	DATE:	02/05/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Melissa Hawthorne-Director		TIME COMPLETED:	02:45 PM

NARRATIVE

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On 2/05/2021 at 2:00 PM, Licensing Program Analyst (LPA) Andrea Taylor conducted a tele-inspection visit with director Melissa Hawthorne, via Face Time, due to COVID-19 and DPH guidelines of social distancing.

LPA Taylor conducted census, reviewed records and conducted interviews.

The purpose of the tele-inspection visit is to conduct a case management, incident inspection in response to the receipt of an unusual incident report (UIR). The UIR was received by the licensing agency on 1/11/21.

Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee.

An exit interview was conducted. A copy of this report was provided to licensee via email with an electronic “READ RECEIPT”. LPA Taylor requested Melissa Hawthorne to acknowledge receipt of the email. The electronic read receipt of the emailed report acknowledges receipt of this report.

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.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Andrea Taylor	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021

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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