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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364800283
Report Date: 01/23/2023
Date Signed: 01/23/2023 12:21:54 PM

Document Has Been Signed on 01/23/2023 12:21 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:PSD/RENAISSANCE HEAD START CENTERFACILITY NUMBER:
364800283
ADMINISTRATOR:MARIA MEDINAFACILITY TYPE:
850
ADDRESS:1360 W. FOOTHILL BLVD.TELEPHONE:
(909) 875-6863
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 105TOTAL ENROLLED CHILDREN: 105CENSUS: 0DATE:
01/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Maria MedinaTIME COMPLETED:
12:35 PM
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On date and time listed above Licensing Program Analysts (LPA) Justin Giese conducted an unannounced visit to the facility to follow up on the submission of an Unusual Incident Report (UIR) that was received by the Regional Office on 12/06/2022. LPA met with Director, Maria Medina, to discuss the purpose of the visit.

On 12/06/2022 Facility Staff self-reported an incident where a child in care reported to staff that their teeth felt loose. UIR stated staff asked the child to show them the loose tooth. For documentation purposes staff noted the Child’s statement on an internal incident/accident form. Staff did not observe the child to have incurred an accident/injury to cause the tooth to come loose, nor did they notice the child was in discomfort, bleeding or in pain. The child remained in care for the duration of the AM session and was released to their parent/guardian. UIR stated the parent/guardian of the Child contacted the facility that same afternoon and reported the Child’s tooth was cracked and bleeding.

Due to facility closure for observation of the holiday schedule, LPA made initial unannounced visit to follow up on submission of this UIR on 01/03/2023. At time of visit LPA interviewed facility staff and reviewed documents. Staff interviews disclosed the Parent/guardian of the child informed facility staff the child was seen by a physician/dentist and would need medical attention and a modified soft foods diet. To meet such accommodations, the facility requested submission of medical documentation from parent/guardian to better meet the child’s needs and informed the child would not be able to attend the facility without these documents. The child remained absent from the facility for the duration of that week and period of holiday closure from 12/16/2022 to 01/03/2023.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: PSD/RENAISSANCE HEAD START CENTER
FACILITY NUMBER: 364800283
VISIT DATE: 01/23/2023
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At time of visit on 01/03/2023 LPA was informed the child had not returned to the facility nor had the facility received the proper medical documentation. On 01/16/2023 LPA contacted the facility via telephone and was informed the child had returned to the facility on 01/16/2023 with no restrictions. LPA was informed the child’s parent/guardian provided the facility with a handwritten note stating the child was free from medical/dental restrictions and they no longer required a soft food modified diet. LPA was provided this document via email.

Based on LPA observations and interview there appear to be no violations of Title 22. Facility documented the Child reporting to staff their tooth felt loose, informed the parent/guardian and documented their concerns with the submission of a UIR. Parent/guardian fulfilled the facility’s request and released the child back to the facility with no restrictions.

An exit interview was conducted, LPA provided Director with a copy of this report and a notice of site visit on 01/23/2023.

Notice of site visit must be displayed for the next 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC809 (FAS) - (06/04)
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