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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197400783
Report Date: 05/10/2019
Date Signed: 05/10/2019 04:20:21 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:CCRC HEAD START-WOODMANFACILITY NUMBER:
197400783
ADMINISTRATOR:SIRANUSH ANDAKYANFACILITY TYPE:
850
ADDRESS:5944/5939/WOODMAN/BUFFALO AVE.TELEPHONE:
(818) 989-2379
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY:120CENSUS: 76DATE:
05/10/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Siranush AndakyanTIME COMPLETED:
04:30 PM
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LPA Christopher Garlington conducted an unannounced Case Management visit for the purpose of investigating an Unusual Incident Report. Upon arrival LPA was guided on a tour indoors and outdoors by Director Siranush Andakyan.

On 04/29/2019, the facility reported an Unusual Incident/Injury via telephone which occurred on 04/25/2019, involving Child #1 who fell while playing on the small sliding board of the playground apparatus. Child #1 struck mouth on the surface of the sliding board injuring the child’s mouth.

LPA obtained a copy of the facility Child Accident Report, facility Medication Consent form, Personnel Report (LIC 500), and the facility roster during the visit.

LPA Christopher Garlington met with and interviewed Child #1, Staff #1, Staff #2, and Staff #3. LPA took photographs of the playground apparatus. Child #1 demonstrated his actions at the time of the incident, and was able to point to staff’s position on the playground.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Christopher GarlingtonTELEPHONE: (424) 301-3056
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CCRC HEAD START-WOODMAN
FACILITY NUMBER: 197400783
VISIT DATE: 05/10/2019
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Based on LPA’s observations and statements by the aforementioned individuals, LPA Garlington has determined there is no need for further investigation. Staff #1 was positioned next to the slide and reacted immediately to Child #1 falling. Simply put, she could not of been closer or reacted sooner. The facility has followed all Title 22 Regulations in the care and supervision of the children and reporting the incident to the Community Care Licensing Division.

LPA provided a copy of the report and a Notice of Site Visit to the facility. An exit interview was also conducted.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Christopher GarlingtonTELEPHONE: (424) 301-3056
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
LIC809 (FAS) - (06/04)
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