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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360900248
Report Date: 05/04/2023
Date Signed: 05/04/2023 10:58:54 AM

Document Has Been Signed on 05/04/2023 10:58 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:PSD/CUCAMONGA HEAD STARTFACILITY NUMBER:
360900248
ADMINISTRATOR:ANITA DELATORREFACILITY TYPE:
850
ADDRESS:9324 SAN BERNARDINO ROADTELEPHONE:
(909) 948-6979
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: 73TOTAL ENROLLED CHILDREN: 73CENSUS: 45DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Arlene Franco TIME COMPLETED:
11:30 AM
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On 5/4/23 at 9:15 am, Licensing Program Analyst (LPA) Patricia Berry conducted a case management visit in response to the receipt of an unusual incident report (UIR) from the facility.The UIR was received by the licensing agency on 4/27/23.

LPA was granted access into the facility and met with Arlene Franco LPA toured facility and took a census. LPA obtained documentation.

Facility records were reviewed, 4 staff were interviewed and 1 child. Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the Site Supervisor.

An exit interview was conducted and a copy of this report, appeal rights and notice of site visit was provided to facility staff.

Notice of Site Visit must be posted for 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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