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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192006365
Report Date: 10/05/2022
Date Signed: 10/05/2022 09:48:53 AM


Document Has Been Signed on 10/05/2022 09:48 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:LANCASTER-LINDA VERDE ELEMENTARY STATE PRESCHOOLFACILITY NUMBER:
192006365
ADMINISTRATOR:FOUNTAIN, KELLYFACILITY TYPE:
850
ADDRESS:44924 N. 5TH STREET EASTTELEPHONE:
(661) 942-5862
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:48CENSUS: DATE:
10/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:kelly FountainTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Carol Heath met Kelly Fountain Director, for a Case Management Incident inspection involving an Incident dated 9/20/2022. LPA spoke with the Nurse Tessiny Holliday on the phone and Diana Barragan in the Office.

Description of the incident: On 10/4/2022, Palmdale Regional Office received an email from the school to report Child#1 had seizure activity during the class hours. 911 was called and Child #1 was transported to AVMC via EMS
LPA received the child#1’s health plan and received a copy of the Roster. Interviews were conducted with Nurse. Pre Nurse, the child #1 had history of Seizure. The Individual Health care plan was in the child’s file.


Based on the information gathered and interviews, staff followed their reporting policy and procedure. No citation issued on this date.

An exit interview was conducted and a copy of the report was read and provided to the Director Kelly Fountain

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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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