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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201899
Report Date: 08/28/2020
Date Signed: 08/28/2020 12:47:23 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:LANCASTER UNITED METHODIST CHURCH PRE SCHOOLFACILITY NUMBER:
191201899
ADMINISTRATOR:DAMON, TAMMYFACILITY TYPE:
850
ADDRESS:918 WEST AVENUE JTELEPHONE:
(661) 942-0812
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:58CENSUS: 12DATE:
08/28/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Director Tammy DamonTIME COMPLETED:
12:49 PM
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On August 28, 2020, Licensing Program Analyst (LPA) Tsutaoka met with Director Tammy Damon using Google Duo. In-person inspections are suspended until further notice due to COVID-19. Director took LPA Tsutaoka on a tour of the day care classroom where incident occurred and LPA observed the train table where Child 1 hit his head. Child 1 was running across the room toward the table and tripped over his own feet, smacking his forehead against the table resulting in a gash. Child 1's mother was notified immediately of the incident and came to pick him up. The parent took Child 1 to urgent care where the doctor determined he needed stitches. The doctor administered 3 stitches to Child 1. Child 1 is attending day care today, 8/28/20. Per Child 1, he bumped his head "over there" when he was running. The child pointed at the train table. LPA observed the bandage on Child 1's forehead and a swollen right eye.
Director showed LPA the train table which has rounded corners, no jagged or damaged edges, and appears in good condition. The table is located against the wall not obstructing the ability for children to walk across the room.
Per director, Child 1 tends to run more than he walks. Child lost his balance and fell forward and hit his head. Per Director, the contusion on his forhead is about the size of a small pinky finger. Director was called by teacher as soon as incident occurred. Director observed the teacher holding an ice pack on his head and towels to soak up the blood. Director made decision to call parent immediately. Director comments Child 1 is a "rough and tumble boy" who tends to be clumsy. He tends to trip and lose balance, but this is the first incident requiring medical attention. LPA recommended to sit down with parent and Child 1 to come up with a plan to prevent Child 1 from running indoors.
Based on the evidence and interviews conducted, no deficiencies will be cited at this time. An exit interview was conducted, and a copy of this report was read and sent via email with read receipt (due to COVID-19) to Director, Tammy Damon.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte TsutaokaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2020
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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