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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830641
Report Date: 10/20/2021
Date Signed: 10/20/2021 11:58:18 AM

Document Has Been Signed on 10/20/2021 11:58 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:MARIA TEELFACILITY TYPE:
830
ADDRESS:10250 KIDD STREETTELEPHONE:
(951) 688-4242
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 28TOTAL ENROLLED CHILDREN: 27CENSUS: 16DATE:
10/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jeni Gonzalez-Executive DirectorTIME COMPLETED:
12:30 PM
NARRATIVE
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On 10/20/2021 at 11:15 AM, Licensing Program Analyst (LPA) Andrea Taylor conducted an inspection visit with Executive Director.

A case management inspection is being conducted in response to the receipt of a self reported unusual
incident report (UIR) from the facility. The UIR was received by the licensing agency on 9/10/21.
The incident occurred on 9/09/21.

The incident is an infant walked out through the doorway to the parking lot when the teacher opened the door. The teacher did not see the child walk out the door. A parent who was in the parking lot returned the child safely to the classroom approximately 1 minute or so later. The door that was opened is never supposed to be opened and the staff have been trained on this both before and after this incident. All person's interviewed during the investigation were consistent the child did walk out and was returned safely.

If a civil penalty has been assessed during this inspection, payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. You will receive an invoice in the mail. Do not send money until you receive your invoice. Do not send cash.

See LIC809-D for cited deficiencies

An exit interview was conducted.
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: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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 10/20/2021 11:58 AM - It Cannot Be Edited


Created By: Andrea Taylor On 10/20/2021 at 11:29 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: 10/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2021
Section Cited
CCR
101429a

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Responsibility for Providing Care and Supervision for Infants
(a)The licensee shall provide care and supervision as necessary to meet the children's needs.
This requirement was not being met as evidenced by:
An infant was found by a parent outside of
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The director stated the staff have been retrained and the staff member who opened the door is no longer employed at the school.
The director will submit an agenda from training with all staff signatures to verify training.

andrea.taylor@dss.ca.gov
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the classroom on the sidewalk.. A teacheropened the door to the parking lot and a child was able to exit the room without the teacher seeing the child exit.
This poses an immediate risk to the Health and Safety of the children in care.
Please note that a $500.00 civil penalty is also being assessed.
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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: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021


LIC809 (FAS) - (06/04)
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