Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334803229
Report Date: 02/21/2018
Date Signed 02/21/2018 01:59:05 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: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: 30DATE:
02/21/2018
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Charlene BrownTIME COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Reginald Smith arrived at the facility on a case management visit to follow-up on an unusual incident report submitted by the facility on 02/09/2018. At the time of visit, LPA toured the facility (specifically where the reported incident took place), took census, and met with Ms. Charlene Brown (Contact Teacher) to discuss the reported incident.

On 02/08/2018 a child was injured while on the playground and sought medical attention.
On previous case management visit LPA interviewed the Teacher(s) who witnessed the incident as it took place. During today’s visit LPA interviewed the child that was involved in the incident was interviewed by the LPA.

Based on the information obtained during the visit, as well as an inspection of the playground and equipment (photographs of file), there appeared to be no violations of Title 22 Regulations pertaining to the reported incident.

An exit interview was held with Ms. Charlene Brown (Contact Teacher). A Notice of Site visit was issued, along with a copy of this report. This report shall be public record for three years.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Reginald SmithTELEPHONE: (951) 505-6432
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1