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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360906598
Report Date: 09/02/2022
Date Signed: 09/02/2022 03:47:31 PM

Document Has Been Signed on 09/02/2022 03:47 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CJUSD/SAN SALVADOR CHILDREN'S CENTERFACILITY NUMBER:
360906598
ADMINISTRATOR:MACK, MELISSAFACILITY TYPE:
850
ADDRESS:471 AGUA MANSA ROADTELEPHONE:
(909) 876-4154
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 54DATE:
09/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melissa MackTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Laura Mejorado arrived at the facility to conduct a case management visit in response to the receipt of an unusual incident report (UIR). The UIR was received by the Riverside Child Care Regional office, on 05/26/2022. The UIR documented an incident where a child fell and sustained an injury to their upper lip which resulted in a tooth falling out.

Upon arrival, LPA met with Director Melissa Mack and stated the purpose of the visit. Records were reviewed and interviews were conducted. The subject child(ren) who was the subject of the UIR was not present and transitioned into another school.

Based on the information gathered and compiled during this visit there was appropriate supervision during the incident which was described as an accident. During todays inspection, no citations were issued, at this time.

Exit interview conducted and report was reviewed with Director Melissa Mack.

A notice of site visit was given and must remain posted for 30 days.

A copy of this report must be made available to the public, at the facility site, for 3 years.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Laura Mejorado
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2022
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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