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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201899
Report Date: 09/21/2021
Date Signed: 09/21/2021 04:54:50 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: 38DATE:
09/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Director Tammy DamonTIME COMPLETED:
05:05 PM
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On September 21, 2021 at 10:34AM, Licensing Program Analyst (LPA) Brigitte Tsutaoka conducted an unannounced Case Management - Incident inspection regarding the self-reported incident involving Child 1 who sustained a head injury during dramatic play. LPA disclosed the purpose of inspection and was granted entry by Staff 1 who checked LPA's temperature. Director joined LPA immediately after entry. Upon entry, LPA counted 38 children in care with 9 staff.

During inspection, LPA interviewed staff, children, toured the facility and observed the Awesome Owls - Pre-K classroom (AO) where incident occurred. On August 26, 2021, Child 1 and Child 2 were in playing costume dress-up in dramatic play pretending to be super heroes. Child 1 charged toward Child 2, embracing Child 2 and tackling him to the ground. Child 2 hit his head on the ground while child 1 hit his eye brow on the corner of the cabinets against the wall in the back right corner of the room, causing a laceration right above Child 1's eyebrow. Staff 2 immediately called Child 1 and Child 2 over to her, where she observed Child 1 covering his eyebrow. When Child 1 removed his hand, Staff 2 observed blood dripping onto his costume.

Staff 2 applied pressure to the incision with paper towels, then took Child 1 to the office where she cleaned him up. Staff 4 obtained an ice pack from the first aid kit and Staff 2 applied the ice pack to Child 1 with a paper towel. Staff 4 contacted Child 1's authorized representative and he was picked up from the facility approximately 15 minutes later. The incision had stopped bleeding and medical attention was not required.
Staff 3 stayed with Child 2, applied ice to the back of his head. Staff 3 monitored Child 2 and rechecked the affected area approximately 30 minutes later, and no bump had developed.
LPA observed the AO classroom and did not observe any hazards that could have contributed to the fall or the classroom in disrepair. LPA observed the classroom being prepped for nap time with mats on the floor and no children inside the classroom.

Based on evidence obtained and interviews conducted, no deficiencies were noted and no citations will be issued today. An exit Interview was conducted, a copy of this Report, Appeal rights and a Notice of Site visit were provided to the Director.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte TsutaokaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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