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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191205095
Report Date: 04/20/2021
Date Signed: 04/20/2021 12:36:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:ALTADENA CHILDREN'S CENTERFACILITY NUMBER:
191205095
ADMINISTRATOR:SHONNA CLARKFACILITY TYPE:
850
ADDRESS:2326 NORTH EL MOLINOTELEPHONE:
(626) 797-6142
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:44CENSUS: 35DATE:
04/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Shonna Clark TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Judy Mora contacted the facility via telephone due to COVID-19 and pre-cautionary measures. LPA Mora identified herself and spoke to Director Shonna Clark and discussed the purpose of the call. The call was then transferred to Face time. LPA conducted interviews and obtained documentation during this visit.

The incident that occurred on Monday 04/14/21, was reported to the Department on 04/14/21 via phone. The facility reported the incident within the required 24 hours.

Based on the information provided during this visit, it was found that child #1 was injured and required medical attention. The child accidentally tripped and fell while chasing after a ball. The child fell and hurt her wrist area resulting in a fracture. This was an isolated incident. LPA observed the area to be safe. A staff did observe the incident occur.

Based on all information obtained on this date, and interviews conducted with staff, no follow-up is necessary regarding the incident. The incident appears to be an unusual accident. It appears to be nothing the facility staff could have done to prevent the incident from occurring.

The Notice of Site Visit (LIC 9213)must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. At this time, the licensee is in compliance with California Title 22 Regulations.

An exit phone interview has been conducted with Director Shonna Clark. A copy of this report has been signed by LPA Mora. This report will be e-mailed to Ms. Clark, who understands that an electronic “Read Receipt” and/or confirmation of receipt of the e-mail confirms receipt of the report and constitutes an electronic signature. A hard copy of this report, will be mailed to Director who agrees to sign the bottom of each page of the LIC 809 and return the originals to LPA Mora in-person or via U.S. Mail.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
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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