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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197400546
Report Date: 05/24/2019
Date Signed: 05/24/2019 04:53:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:HARRY A. MIER CENTERFACILITY NUMBER:
197400546
ADMINISTRATOR:JAE LIMFACILITY TYPE:
840
ADDRESS:8090 CRENSHAW BLVDTELEPHONE:
(323) 753-3101
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY:27CENSUS: 1DATE:
05/24/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Jae LimTIME COMPLETED:
05:07 PM
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Licensing Program Analyst (LPA), Keyona Scott, conducted an unannounced Case Management Inspection to the Center on 05/24/19 at 2:07 PM. The purpose of the inspection was to investigate the Unusual Incident that occurred on 05/15/2019 with Child #1. LPA met with Director Jae Lim at 2:15 PM. LPA was lead on a tour of the facility with Director on 05/24/19 at 2:20 PM. There are no changes to the facility layout or the off-limit areas of the Center. There was one child present at the time of the inspection. The child that was involved in the incident (Child #1) had not yet arrived at the facility when LPA began the inspection.

Per the report that was received at the El Segundo Regional Office, Child #1, had a reaction and began to break out in hives and face began to swell on 05/24/2019 at approximately 5:30 PM.

Director states was not present at the facility at the time the Unusual Incident occurred with Child # 1 on 05/15/19. Director states had left Center for the day approximately ten minutes prior to the incident occurring.

LPA interviewed one staff # 1 and Child #1 on 05/24/19. The other staff present at the time of the Unusual Incident were not present during today's inspection.

During today's inspection LPA reviewed Child #1 file and obtain a copy of the menu and Child #1 Time Card for the period 05/13/2019 through 05/17/2019 and LIC 700 (Identification and Emergency Information).

LPA must obtain additional information regarding the incident prior to concluding the investigation into the Unusual Incident.

No deficiency cited at this time.

A copy of this report and the Notice of Site Visit (LIC 9213) was issued to the Director, Jae Lim, whose signature confirms today's inspection and report.
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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2019
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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