Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334803229
Report Date: 02/15/2018
Date Signed 02/15/2018 10:38:58 AM

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:RCOE - JEFFFERSON HEADSTARTFACILITY NUMBER:
334803229
ADMINISTRATOR:YVETTE TESTAFACILITY TYPE:
850
ADDRESS:1040 S. VICENTIA AVENUETELEPHONE:
(951) 340-1526
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:37CENSUS: 29DATE:
02/15/2018
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Maribal HernandezTIME COMPLETED:
10:40 AM
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Licensing Program Analysts Reginald Smith and Ana Noble arrived at the facility to follow up on an unusual incident report. LPA's met with Maribell Hernandez Community Assistant.

On 2/8/18 at 4:16 PM While on the playground a child was running from the grass area to the playground structure and tripped over her feet landing on the ground resulting in a broken left arm. The parent was notified and the child was taken to Corona Regional Hospital by ambulance.

Staff, who was present and witnessed the incident and immobilized the child's arm and kept the child calm until was called 911.

During today's visit, LPA’s spoke to staff about the incident, observed the area of the playground where the incident occurred, The child was not not present for LPA's to interview therefore this visits will be extended to gather additional information.

An exit interview was conducted and a copy of this report was provided to the Director.

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Reginald SmithTELEPHONE: (951) 505-6432
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2018
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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