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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191599976
Report Date: 01/21/2020
Date Signed: 01/21/2020 11:51:46 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:NIEMES HEADSTART/STATE PRESCHOOLFACILITY NUMBER:
191599976
ADMINISTRATOR:LIDA BELTROCCOFACILITY TYPE:
850
ADDRESS:16715 S JERSEY AVENUETELEPHONE:
(562) 229-7958
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY:40CENSUS: 25DATE:
01/21/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Education CoordinatorTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPAs), Tiffanie Tran and Mayra Rivera conducted a Case Management inspection at the above facility to follow up on the self-reported incident that occurred on 10/15/2019. The Monterey Park South West Child Care Regional Office received the incident report on 10/17/2019.

LPAs conducted files review and obtained child's document. Interviews were conducted with staff and other. Based on the information that were available center staff stated, C1 was playing in the manipulative area with lego as child reach to pick up a lego he hit his left eye on the corner of the table. Child sustained a laceration below the left eye brow. No other children were involved. Parent was contacted. Child was taken to the doctor and glue procedure was provided. Child missed two days of school. At this time based on the available information it does not appear this incident was the result of a Title 22 violation.

The content of this report was read and discussed in detail at the time of with the noted contact 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: 01/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2020
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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