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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364801214
Report Date: 12/01/2022
Date Signed: 12/01/2022 01:04:36 PM

Document Has Been Signed on 12/01/2022 01:04 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:PSD/ONTARIO HEAD STARTFACILITY NUMBER:
364801214
ADMINISTRATOR:WILLIAM ALVAREZFACILITY TYPE:
850
ADDRESS:555 W. MAPLE AVENUETELEPHONE:
(909) 984-4117
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 224TOTAL ENROLLED CHILDREN: 224CENSUS: 98DATE:
12/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:William Alvarez/DirectorTIME COMPLETED:
01:20 PM
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On 12/1/22 at 10:04 am Licensing Program Analysts "LPA's" Claudia Caywood and Patricia Berry conducted a case management investigation. LPA's investigated two Unusual Incident Reports. One on 11/10/22 and 11/21/22. LPA's were granted access in to the facility and met with the Director. LPA's toured facility and took a census.
LPA's interviewed staff and children and obtained documentation.

Director self reported two Unusual Incident Reports, one on 11/10/22 and 11/21/2022. The Director stated he conducted his own internal investigation. Due to insufficient information at this time. LPA's will need to return at a later date to conclude the outcome of the Unusual Incident Reports.

Exit interview conducted with Director, Report, Appeal Rights, and Notice of Site visit provided to the Director.

Notice of Site visit must be posted for 30 Days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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