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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191890481
Report Date: 07/18/2023
Date Signed: 07/18/2023 02:27:34 PM


Document Has Been Signed on 07/18/2023 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:PACOIMA EARLY EDUCATION CENTERFACILITY NUMBER:
191890481
ADMINISTRATOR:SUSAN HANFACILITY TYPE:
850
ADDRESS:11059 HERRICK ST.TELEPHONE:
(818) 896-3722
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY:115CENSUS: 51DATE:
07/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Sheila Hardy, Principal TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Lilia Hernandez conducted an unannounced case management inspection due to an incident that occurred on 07/17/2023. LPA arrived at the facility at 1:30PM and met with Sheila Hardy, Principal, who guided LPA on a tour of the facility. There were 51 children and 16 staff present upon arrival.

The purpose of the visit was to follow-up on an incident that was reported to the department.

LPA Hernandez conducted interviews and obtained documentation during this visit.

The incident that occurred on 07/17/2023, was reported to the Department on 07/17/2023, via telephone. The facility reported the Unusual Incident to the Department within the required 24 hours of occurrence.

Information reported to the Department indicated that child #1 was playing near the apparatus with other children. Staff witness Child#1 run into the apparatus. Child #1 forehead started to bleed and staff administered first aid. Parent was notified and issued a head injury report and advised to seek medical attention for child. Facility required a doctor’s note and/or clearance before child can return to care.

Child #1 returned to care on 7/18/2023 with a doctor's note. No restrictions were documented on the doctors note.

Based on interviews conducted and documentation obtained, there were no deficiencies cited during today’s inspection.

A notice of site visit was given and must remain posted for 30 days.



Exit interview conducted and report was reviewed with Sheila Hardy, Principal.
SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia HernandezTELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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