Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600287
Report Date: 02/20/2019
Date Signed: 02/20/2019 01:21:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CAJON VALLEY STATE PRESCHOOL-RIOS ELEMENTARYFACILITY NUMBER:
376600287
ADMINISTRATOR:MARIA KEHOEFACILITY TYPE:
850
ADDRESS:14314 RIOS CANYON ROADTELEPHONE:
(619) 588-3090
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY:25CENSUS: 0DATE:
02/20/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Tere Hanna Teacher TIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Michelle Hood, made an unannounced visit to follow up on a self reported incident on 01/31/2019, a 4.5 year old child (Child #1) was outside motioning punch movements and running around with another child. While running child #1, continuously looked over his right shoulder. Child #1 started to cry due pain on the right side of his neck. Child sustaining a muscle strain.

LPA interviewed two staff members. There were no children in care at the time of visit. No obvious hazards were noted and neither staff stated there was any inappropriate behavior that would have led to the incident. It appears that this was a random incident. Child returned back to school on 02/04/2019.

Ratios were met, supervision was in place, the staff responded appropriately and the facility reported timely. No deficiencies are cited.
SUPERVISOR'S NAME: Jason GarayTELEPHONE: (559) 243-4588
LICENSING EVALUATOR NAME: Michelle HoodTELEPHONE: (619) 767-2241
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2019
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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