143808559-12-14-2020-12-CC-BTSA-BWARZV-20201214122834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 143808559
Report Date: 12/14/2020
Date Signed: 12/14/2020 12:30:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	IMACA ELM STREET PRESCHOOL		FACILITY NUMBER:	143808559
ADMINISTRATOR:	AMANDA TATUM		FACILITY TYPE:	850
ADDRESS:	800 W. ELM ST., BLDG A		TELEPHONE:	(760) 872-6832
CITY:	BISHOP	STATE: CA	ZIP CODE:	93514
CAPACITY:	20	CENSUS: 8	DATE:	12/14/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Site Supervisor Amanda Tatum		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On December 14, 2020, Licensing Program Analyst (LPA) Brigitte Tsutaoka contacted Site Supervisor Amanda Tatum to conduct an unannounced Case Management - Incident inspection. LPA stated the purpose of the inspection and proceeded to interview witnesses. LPA conducted the tele-inspection over the phone as a COVID-19 safety precaution. Per Site Supervisor, there are 8 children in care today. At 10:04AM, LPA interviewed Site Supervisor who stated on November 12, 2020, she and Staff 1 were present providing supervision to the children at a field trip to Bishop City Park, placing themselves on opposite sides of the play structure. Site Supervisor was approximately 5 feet away from the structure where Child 1 and Child 2 were playing. Site supervisor observed both children climb a ladder to the play structure which could fit approximately 3 children wide. Child 2 nudged Child 1 with his left arm in an attempt to climb ahead of Child 1. Child 1 lost his balance and fell approximately 2 feet off the ground on to the cushioned playground flooring. Right when Child 1 began to lose his balance, Site Supervisor rushed over to Child 1, but was unable to make it to him before he hit the ground. Once Child 1 hit the ground he began to cry and Site Supervisor picked him up to console him. Child 1 stated his arm hurt, but he wanted to continue playing. Site supervisor contacted Child 1's mother and explained he fell and hurt his arm. Per Site Supervisor, Child 1's mother stated to monitor him and to notify her of any updates. Site Supervisor noticed Child 1 favoring his left arm and disclosed to the mother when she came to pick him up. Child 1's mother took Child 1 to emergency room the following day, November 13, 2020 because Child 1 was showing discomfort through the previous night. Child 1 returned the following Monday to the facility, and has not complained of pains in his arm since the incident.

SUPERVISOR'S NAME: Carissa Bell	TELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte Tsutaoka	TELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: IMACA ELM STREET PRESCHOOL	FACILITY NUMBER: 143808559
	VISIT DATE: 12/14/2020

NARRATIVE

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At 10:51AM, LPA interviewed Staff 1 who stated she did not witness the incident as she was on the other side of the play structure. Staff 1 stated Site Supervisor walked over to her while holding Child 1 who was crying, and explained he had fallen off the play structure. Child 1 cried for approximately 2 minutes and then wanted to continue playing. Staff 1 was providing supervision to the children while Site Supervisor contacted Child 1's parent to notify them of the incident.

At 11:00AM, LPA attempted to interview Child 2, but Child 2 is nonverbal.

At 11:04AM, LPA interviewed Child 1 who stated Child 2 pushed him off "the green thing" and he fell. He stated he did not accrue any "owies," but he did cry.

Based on information provided and interviews conducted the incident does not appear to have been the result of any violation of the Title 22 regulation, therefore, no deficiencies were cited.

Exit interview conducted and a copy of this report will be emailed with read receipt to Site Supervisor as a COVID-19 safety precaution. Report will also be certified mailed to Site Supervisor. The read receipt is in lieu of a signature.

SUPERVISOR'S NAME: Carissa Bell	TELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte Tsutaoka	TELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2020

LIC809 (FAS) - (06/04)

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