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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601954
Report Date: 06/18/2019
Date Signed: 06/18/2019 10:51:03 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:AMY AGNEWFACILITY TYPE:
830
ADDRESS:101 S. BELLAGIO DR.TELEPHONE:
(310) 825-5086
CITY:LOS ANGELESSTATE: CAZIP CODE:
90095
CAPACITY:60CENSUS: 25DATE:
06/18/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:19 AM
MET WITH:Amy Agnew, Center DirectorTIME COMPLETED:
11:00 AM
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 06/18/2019 at 08:19 am, Licensing Program Analysts (LPAs) Sabrina Martinez and Angelica Ramirez arrived at UCLA Early Care and Education-Infants for the purpose of following up on the unusual incident that occurred at the facility on 05/28/2019. The El Segundo Regional Child Care Office received the report via phone call on 05/31/2019.

According to the report, on 05/28/2019 at approximately 08:50 am, child was walking away from an activity when he lost his balance and bumped left ear on the corner of a toy shelf located inside the classroom. The child had a small cut behind the ear and swelling of the ear.

During this inspection, LPAs conducted interviews with facility staff and the child's parent. LPAs conducted a tour of the classroom, obtained a copy of the injury report dated 05/28/19, physician's report as well as a copy of the sign in and sign out sheet dated 05/28/19.

Based on the information obtained throughout the course of the investigation, it does not appear that the incident was a result of a Title 22 violation.

At the time of the incident, the classroom was staffed with 3 adults supervising 10 infants. 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: 06/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019
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