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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191597736
Report Date: 10/19/2021
Date Signed: 10/19/2021 11:59:58 AM

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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CARVER HEAD START/STATE PRESCHOOLFACILITY NUMBER:
191597736
ADMINISTRATOR:ROSELIA GOMEZFACILITY TYPE:
850
ADDRESS:19200 ELY STREETTELEPHONE:
(562) 229-7933
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:38CENSUS: 19DATE:
10/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Evelyn Numez, TeacherTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) T. Tran arrived at above licensed facility to conduct a Case Management inspection that was self-reported on 09/02/2021 regarding a child in care had consumed a food allergy item during snack. The Monterey Park South West Child Care Regional Office received the incident report on 09/03/2021.

About 9:10 AM LPA toured the facility indoor and outdoor. Files review were conducted, and document were obtained. On the day of the incident, there 2 staff supervised 08 children. Based on the information that were gathered during today's interviews and record review indicated, child has food allergy for dairy/milk. During snack time, staff served child cheese stick then, realized child might not be able to consume then taken it away. Parent was contacted and confirmed that child has no food allergies for cheese. At this time based on the available information it does not appear this incident was the result of a Title 22 violation for personal rights. No deficiency was cited.

The content of this report was read and discussed in detail with the noted person.

An exit interview was conducted; the notice of site visit must be posted for 30 days upon receipt.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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