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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
153808551
Report Date:
09/27/2019
Date Signed:
09/27/2019 03:42:42 PM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1605 EAST PALMDALE BLV, STE A
PALMDALE
,
CA
93550
FACILITY NAME:
FALLER STATE PRESCHOOL
FACILITY NUMBER:
153808551
ADMINISTRATOR:
ALLEN, DENISE, R
FACILITY TYPE:
850
ADDRESS:
1500 WEST UPJOHN
TELEPHONE:
(760) 499-1694
CITY:
RIDGECREST
STATE:
CA
ZIP CODE:
93555
CAPACITY:
24
CENSUS:
18
DATE:
09/27/2019
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
02:15 PM
MET WITH:
Kim Thompson
TIME COMPLETED:
04:01 PM
NARRATIVE
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Licensing Program Analysts (LPA) San and Licensing Program Manager (LPM) Claretta Yates conducted an unannounced visit at the Faller State Preschool. During the afternoon section from 12:30-4:00pm. The purpose of this visit was to conduct a Case Management - Incident Inspection. On 09/23/19 The Palmdale Child Care Office received an unusual incident repo
rt regarding child#1 who fell and bump his head on the monkey bar (see Confidential Name list LIC811) dated 09/27/2019. There was 20 children and (3) Staff present on the day of the incident.
LPM and LPA met with Kim Thompson Lead Supervisor and conducted interviews with child#1 and (3) staff.
Based on the interviews it was revealed that child#1 fell off the monkey bars and injured his ears and bump his head. There was bruises observed on child#1 head and ear. First aid was applied "Ice Pack." Parent was notified. Parent arrived to the facility and transported child to Ridge Crest Regional Hospital for observation. Child returned to school the next day.
Child was being supervised during the time of the injury.
No deficiencies were cited during this inspection.
An exit interview was conducted. A copy of this report and notice of Site Inspection was provided to the Lead Supervisor Kim Thompson and shall be posted for 30 days.
SUPERVISOR'S NAME:
Claretta Yates
TELEPHONE:
(661) 789-6944
LICENSING EVALUATOR NAME:
Jacky San
TELEPHONE:
(661) 305-3690
LICENSING EVALUATOR SIGNATURE:
DATE:
09/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/27/2019
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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