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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191606626
Report Date: 01/08/2020
Date Signed: 01/09/2020 04:19:41 PM

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:MELBOURNE HEAD START/STATE PRESCHOOLFACILITY NUMBER:
191606626
ADMINISTRATOR:ISABEL DELGADILLOFACILITY TYPE:
850
ADDRESS:21314 CLARETTATELEPHONE:
(562) 229-7931
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY:37CENSUS: 28DATE:
01/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Education CoordinatorTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA), Tiffanie Tran conducted a Case Management inspection at the above facility to follow up on the self-reported incident that occurred on 06/07/2019. The Monterey Park South West Child Care Regional Office received the incident report on 06/07/2019. Reporter stated, a child in care had a seizure.

LPA completed child reviewed. LPA obtained personnel and child’s documentation. Staff and children were interviewed. Based on the information that were gathered through interviews this incident occurred last school year. During circle time, S1 observed C1 fell then began shaking and vomiting. Staff immediately called 911 and parent was contacted. Parent stated, child has febrile seizures. This was the first episode that occurred at school. No other episode observed. Staff provide increase monitoring daily and remind child to drink water to prevent from dehydration.

Incidental Medical Services (IMS) were reviewed. The facility does provide IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children's, personnel and administrative records. Child had Motrin at the facility as needed.



At this time, no deficiencies were observed or cited in relation to this incident. 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: 01/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020
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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