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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334812347
Report Date: 10/11/2023
Date Signed: 10/11/2023 01:58:29 PM

Document Has Been Signed on 10/11/2023 01:58 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:RCOE-PERRIS HEAD START STATE PRESCHOOL EARLY HEADFACILITY NUMBER:
334812347
ADMINISTRATOR:LORI WIEDENSOHLERFACILITY TYPE:
850
ADDRESS:148 AVOCADO AVENUETELEPHONE:
(951) 826-7200
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 165TOTAL ENROLLED CHILDREN: 153CENSUS: 76DATE:
10/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Jenna SotoTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Keely Messerschmidt arrived at the facility on a case management inspection to follow-up on an Unusual Incident Report (UIR) which occurred on September 5th, 2023 per Site Manager. LPA met with Secretary Jenna Soto, and provided purpose of inspection. At the time of inspection, LPA toured the facility, took census, interviewed and reviewed documents previously submitted to the department with Secretary.

The reported incident took place on September 5th, 2023, regarding C1 being given milk that he was allergic to, which required the administration of C1's epi-pen and 911 being contacted. Based on information obtained a deficiency is being cite, see LIC809-D.

An exit interview was conducted with Secretary Jenna Soto, Appeal Rights were discussed and a copy of this report was provided along with the Notice of Site visit.

Notice of site visit must remain posted for 30 days.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
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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Document Has Been Signed on 10/11/2023 01:58 PM - It Cannot Be Edited


Created By: Keely Messerschmidt On 10/11/2023 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: RCOE-PERRIS HEAD START STATE PRESCHOOL EARLY HEAD
FACILITY NUMBER: 334812347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
101223(a)(2)

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101223 Personal Rights (a)The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This was not met as evidenced by,
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 Secretary agrees to have staff receive a trianing on updated policy and send proof of training and new policy to LPA via email by 10/20/23.
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After record review, Unusual Incident Report (UIR) stated child was given milk when he had an identified allergy and epi-pen on site. Staff provided child with milk, which required the epi-pen to be administered and 911 to be contacted. This is a potential risk to the health and safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Deborah Mullen
LICENSING EVALUATOR NAME:Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


LIC809 (FAS) - (06/04)
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