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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830641
Report Date: 04/02/2021
Date Signed: 04/02/2021 09:25:34 AM

Document Has Been Signed on 04/02/2021 09:25 AM - 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:KIDD STREET PRESCHOOL OF RIVERSIDEFACILITY NUMBER:
334830641
ADMINISTRATOR:MELISSA HAWTHORNEFACILITY TYPE:
830
ADDRESS:10250 KIDD STREETTELEPHONE:
(951) 688-4242
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 28TOTAL ENROLLED CHILDREN: 0CENSUS: 11DATE:
04/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Melissa Hawthorne-DirectorTIME COMPLETED:
09:30 AM
NARRATIVE
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On 4/2/2021 at 8:30 AM, Licensing Program Analyst (LPA) Andrea Taylor conducted a tele-inspection visit with director Melissa Hawthorne, via Face Time, due to COVID-19 and DPH guidelines of social distancing.

The purpose of the tele-inspection visit is to conduct a case management, incident inspection in response to the receipt of a self reported unusual incident report (UIR) received by the licensing agency on 1/11/21.

LPA conducted census via Facetime. There were 11 infants and 4 staff present in the infant room.

The self reported incident was described as one infant was given a bottle belonging to another infant. The infant did drink some of the formula from this wrong bottle which contained different milk from their own. The infant did not have any negative reaction to the formula. The bottles are prepared at home and brought to the center by the parents each day. The infant’s bottles are labeled with children’s names and dates. It was disclosed during interviews the two infant’s bottles look almost identical and the staff did not check the name on the label.

The staff were retrained regarding the school’s infant feeding policy and procedure. Verification of this training was submitted to LPA and is the file. In the areas that were evaluated, the facility was not in compliance and violation(s), in accordance with California Code of Regulations, Health & Safety 1596.7995(a)(1), 101223 Personal Rights (a)(2) is being cited on the attached LIC 809D

If the facility receives a Type A violation, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Andrea Taylor
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2021
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 04/02/2021 09:25 AM - It Cannot Be Edited


Created By: Andrea Taylor On 04/02/2021 at 09:09 AM
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KIDD STREET PRESCHOOL OF RIVERSIDE
FACILITY NUMBER: 334830641

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/02/2021
Section Cited
CCR
101223(a)(2)

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101223 Personal Rights (a)(2)
Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Director immediately notified both parents; sent unusual incident report to the Department on 1/12/21. Director conducted an in-service training on 1/8/21 of feeding practices and procedures. Agenda and sign in sheet have been submitted.
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This requirement was not met as evidenced by Staff fed an infant in care the wrong bottle with a different milk, even though bottles are clearly labeled as to whom the bottle belongs.

This is an immediate 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:Aaron Ross
LICENSING EVALUATOR NAME:Andrea Taylor
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2021


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KIDD STREET PRESCHOOL OF RIVERSIDE
FACILITY NUMBER: 334830641
VISIT DATE: 04/02/2021
NARRATIVE
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An exit interview was conducted. A copy of this report was provided to licensee via email with an electronic “READ RECEIPT”. LPA Taylor requested Melissa Hawthorne to acknowledge receipt of the email. The electronic read receipt of the emailed report acknowledges receipt of this report.

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door.


SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Andrea Taylor
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021
LIC809 (FAS) - (06/04)
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