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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870652
Report Date: 05/29/2024
Date Signed: 05/29/2024 11:38:01 AM


Document Has Been Signed on 05/29/2024 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:DOLORES STREET EARLY EDUCATION CENTERFACILITY NUMBER:
191870652
ADMINISTRATOR:MIRA HAGOODFACILITY TYPE:
850
ADDRESS:22309 CATSKILL AVETELEPHONE:
(310) 830-6987
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:116CENSUS: 101DATE:
05/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mira Hagood, PrincipalTIME COMPLETED:
11:45 AM
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On 05/29/2024 at 10:15 AM, Licensing Program Analyst (LPA) Katrina Chicote conducted an Unannounced Case Management inspection to follow up on an incident that was reported to the Department on 04/22/2024. Upon arrival, LPA announced purpose of inspection and met with Facility Representative, Mira Hagood, Principal. Census was taken.

On 04/22/2024, an incident was reported to the Department where a child sustained an injury requiring medical while in care. The facility reported this incident to the Department within the required 24 hours and submitted a written report within seven days.

During this inspection, LPA was provided tour of where incident took place and interviewed Teacher who stated she observed incident. Teacher pointed out track area where child was running and Teacher observed child fall during transition period from outdoor play time. LPA observed surface of outdoor play area to be maintained at time of inspection. Teacher states she applied First Aid immediately and child stayed with her and communicated incident to child's Authorized Representative via Class Dojo. Child was picked up early, after lunch time, and returned the next day with a cast on. Per interviews, they did not observe arm swell up to indicate any fracture or broken bones at time of incident. Child's Authorized Representative chose to keep child home for extended period of time, though record review of doctor's note provided stated child could return but with limited physical activities. Child returned on 05/21/2024 with doctor's clearance note, and upon record review, doctor's note clears child to be present at facility with no limitations. LPA observed child present during today's inspection with no cast on and engaging in activities outside during inspection.

Based on LPA's interviews, observation, and record review, there was adequate supervision during day of incident and immediate first aid was administered and Child's Authorized Representative informed. No deficiencies cited today, 05/29/2024.

A notice of site visit was given and must remain posted for 30 days.
Exit interview was conducted and report was reviewed with the Facility Representative, Mira Hagood.
Report Ends - Page 1 of 1
SUPERVISOR'S NAME: Denise GibbsTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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