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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600175
Report Date: 02/28/2020
Date Signed: 02/28/2020 11:07:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:COVENANT PRESBYTERIAN CHURCH PRESCHOOLFACILITY NUMBER:
191600175
ADMINISTRATOR:SULTAN, KATHLEENFACILITY TYPE:
850
ADDRESS:6323 WEST 80 STREETTELEPHONE:
(310) 670-5758
CITY:LOS ANGELESSTATE: CAZIP CODE:
90045
CAPACITY:74CENSUS: 65DATE:
02/28/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Kathleen SultanTIME COMPLETED:
11:15 AM
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On 02/28/2020, Licensing Program Analyst (LPA) Karren Starks made an unannounced visit for the purpose of conducting a Case Management inspection for an injury that occurred on 01/16/2020, with report being made and received on 01/17/2020.

Per the report on 01/16/2020 at 2:05 pm staff heard loud crying out in the front of the school on the 80th Street side. Staff went to see what occurred and who was crying when they observed C1's mother having to remove the child's leg from being entangled in his bicycle. Staff assisted Mother with contacting Father who arrived to the facility and the child was taken for medical attention. Child's right leg was broken.

Per review of the sign in/out sheet for the facility child was signed out by Mother at 1:55pm on 01/16/2020 and the bicycle the child was riding was the child's property.

Child has returned to school, currently with cast and is currently mobile in a wheelchair with a reduction in hours.

Based on the information obtained Child 1's injury is not due to the result of a Title 22 violation of Personal Rights or Lack of Supervision.

No deficiency Cited.

Copy of Report and Notice of Site Visit issued.
SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2020
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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