<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601954
Report Date: 05/29/2019
Date Signed: 05/31/2019 08:09:57 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:UCLA EARLY CARE AND EDUCATION-INFANTSFACILITY NUMBER:
191601954
ADMINISTRATOR:BALLENTINE, SUEFACILITY TYPE:
830
ADDRESS:101 S. BELLAGIO DR.TELEPHONE:
(310) 825-5086
CITY:LOS ANGELESSTATE: CAZIP CODE:
90095
CAPACITY:60CENSUS: 38DATE:
05/29/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Amy Agnew, Center DirectorTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/29/2019 at 12:20 pm, Licensing Program Analyst (LPA) Sabrina Martinez conducted a case management-incident inspection at the facility for the purpose of following up on the unusual incident that occurred on 04/08/2019. The El Segundo Regional Child Care Office received the report via phone call on 04/10/2019 and the Unusual Incident/Injury Report was received via fax on 04/12/2019. LPA met with Amy Agnew, Center Director, and discussed the purpose of the visit.

According to the report, on 04/08/19 at 10:15 am, child #1 was sitting for circle time and swung her right arm and bumped her forearm on the shelf. The child cried and held her arms and told teachers that it hurt. Staff members tended to the child and applied ice to the area. Mother was immediately notified of the incident. The child was taken to the Emergency Room and an x-ray was taken but no treatment was necessary. The child returned to school on 04/09/19.

During this inspection, LPA conducted interviews with staff members and the child's parent. LPA also obtained a copy of the sign in and sign out sheet dated 04/08/2019. At the time of the incident, the classroom was staffed with 3 teachers supervising 9 children. Based on the information obtained, it does not appear that this incident was a result of a Title 22 violation. Facility staff provided proper care and supervision during the time of the incident. The facility also followed Title 22 Regulations in the care and supervision of the children and reporting the incident to the Community Care Licensing Division.


An exit interview was conducted and a copy of this report along with the Notice of Site Visit were provided to Amy Agnew, Center Director.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1