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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191224046
Report Date: 06/03/2019
Date Signed: 06/03/2019 04:15:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:VERDUGO HILLS FAMILY YMCAFACILITY NUMBER:
191224046
ADMINISTRATOR:LINDSEY WHITESIDE CORTESFACILITY TYPE:
850
ADDRESS:6840 FOOTHILL BOULEVARDTELEPHONE:
(818) 352-3255
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:68CENSUS: 59DATE:
06/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Suzanne McMillenTIME COMPLETED:
02:13 PM
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Licensing Program Analyst Lawson, met with Director Suzanne McMillen. Case Management Incident inspection involving an Incident Report dated May 24th 2019 The incident occurred on May 23rd 2019.

Description of the incident: Child #1 was injured by Child #2 when an object was thrown at him. Child #1 needed medical attention.

Initial interview had to be conducted before 2:30PM.

Based on information provided and interview conducted the incident will require additional information and investigation.

An exit interview was conducted and a copy of this report was read and provided to Suzanne McMillen on this date.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Tyicee LawsonTELEPHONE: (661) 568-8103
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2019
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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