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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870741
Report Date: 05/03/2019
Date Signed: 05/03/2019 03:54:35 PM

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:HAWAIIAN AVENUE EARLY EDUCATION CENTERFACILITY NUMBER:
191870741
ADMINISTRATOR:AGUET, DEBORAHFACILITY TYPE:
850
ADDRESS:501 HAWAIIAN AVE.TELEPHONE:
(310) 834-7186
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY:117CENSUS: 87DATE:
05/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Bernadette GuerreroTIME COMPLETED:
04:00 PM
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On 05/03/19 Licensing Program Analyst (LPA) Karren Starks made an unannounced visit to conduct a Case Management inspection due to an Unusual Incident that occurred on 04/23/19 and reported to the Department on 04/24/2019. LPA spoke with Lead Teacher, Bernadette Guerrero due to the Director being at another site.

Per the report received at the El Segundo Child Care Regional Office, Child 1 had a fractured right wrist.

LPA must obtain additional information regarding the incident prior to concluding the investigation into the Unusual injury.

No deficiency cited.

Copy of report and Notice of Site Visit issued.
SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
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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