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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870869
Report Date: 10/15/2021
Date Signed: 10/15/2021 02:54:01 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:MAOF CHILD CARE CENTER TELEGRAPHFACILITY NUMBER:
191870869
ADMINISTRATOR:RAMIRO RIVERAFACILITY TYPE:
850
ADDRESS:4457 TELEGRAPH ROADTELEPHONE:
(323) 263-9507
CITY:LOS ANGELESSTATE: CAZIP CODE:
90023
CAPACITY:142CENSUS: 25DATE:
10/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Site Supervisor Vilma De LeonTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Jeanette Estrada arrived at MAOF -Telegraph Center to conduct a Case Management inspection regarding an incident that was self-reported on 10/12/2021. Per the Unusual Incident Report submitted to the Regional Office, a child in care was running, tripped and fell and as a result, the child was taken to the hospital and surgery was required.

LPA initially met with Lead Teacher Tina Hernandez, who guided LPA on a tour of the facility at around 1:30PM. Site Supervisor Vilma De Leon arrived a few minutes later and continued with the tour of the outdoor area. LPA interviewed Site Supervisor and Staff 1. Staff 2 who observed the incident and wrote the report was not present during today's inspection. LPA also obtained a copy of the incident report given to Child 1's parent.
Per staff interviews, on the day of the incident, there were two staff supervising 3 children. Child 1 fell on top of child 2 who had already tripped after losing their balance. Child 1 fell with their weight on their right elbow. Per Site Supervisor, they recommended medical assistance to parent. Child had a fractured elbow and required surgery. Child will return once medical documentation is submitted to the center so a Health Plan can be created to accommodate child's needs. Children were in the play structure area of the yard when incident occurred. There is thick rubber cushioning surrounding the area where the children fell. LPA did not observe any hazards.

Based on the information that was gathered during today's interviews, it does not appear this incident was the result of a Title 22 violation. No deficiency was cited.

The content of this report was read and discussed in detail with the noted person.

An exit interview was conducted; the notice of site visit must be posted for 30 days upon receipt.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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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