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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192002562
Report Date: 04/08/2022
Date Signed: 04/08/2022 09:43:21 AM


Document Has Been Signed on 04/08/2022 09:43 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
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: 31DATE:
04/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Adriana Perez TIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Judy Mora conducted a case management inspection due to an incident that occurred on 02/23/22. LPA met with Site Supervisor, Adriana Perez. LPA was guided on a tour of the facility at approximately 8:50 AM.

On 02/23/22 a child tripped on a step on the smaller outdoor apparatus. The child fell to the ground and landed on his left elbow. The injury required medical attention. The child sustained a fracture on his elbow and a cast was placed on the left arm. The child is currently in attendance at the facility.

LPA conducted staff interview and obtained documentation during this visit. LPA also visually observed C1 in the classroom. LPA Mora also visually inspected the area where the incident occurred and photo was taken.

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. Per staff they have changed the transitioning process from outdoors to indoors for the children to move at a slower pace.

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, Site Supervisor.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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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