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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192002562
Report Date: 09/15/2021
Date Signed: 09/15/2021 12:42:00 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:ANGELINA PRESCHOOLFACILITY NUMBER:
192002562
ADMINISTRATOR:PEREZ, ADRIANAFACILITY TYPE:
850
ADDRESS:1336 ANGELINA STREET #108TELEPHONE:
(213) 481-0227
CITY:LOS ANGELESSTATE: CAZIP CODE:
90026
CAPACITY:73CENSUS: 40DATE:
09/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Adriana Perez TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) conducted a case management inspection due to an incident that occurred on 07/29/21. LPA met Director, Adriana Perez, who guided LPA on a tour of the facility at approximately 11:55 AM. During this inspection LPA observed 14 children with 03 staff in P1, 15 children in P2 with 03 staff and 11 children outdoors with 03 staff.

The incident that occurred on Thursday 07/29/21 was reported to the Department on 07/29/21. The facility reported the incident in a timely manner.

LPA conducted an interview and obtained documentation during this visit. LPA also visually observed the space where the incident occurred. On 07/29/21 a child tripped inside a classroom and hit his forehead against a toy shelf. The injury required medical attention. LPA observed that the facility placed a border protector on the edge of shelf in an attempt to prevent any future incident.

Based on all information obtained on this date, no follow-up is necessary regarding the incident. The incident appears to be an unusual accident. It appears to be nothing the facility staff could have done to prevent the incident from occurring.

The Notice of Site Visit (LIC 9213)must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Adriana Perez. Appeal rights explained & provided.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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