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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197400860
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:05:32 PM

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:VOA/PLAINVIEW HEADSTARTFACILITY NUMBER:
197400860
ADMINISTRATOR:NAIRA KUCHAKHCHIANFACILITY TYPE:
850
ADDRESS:10819 PLAINVIEW AVE RMS 8&10TELEPHONE:
(818) 352-5974
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:34CENSUS: 19DATE:
10/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Site Supervisor Rose Coorough TIME COMPLETED:
12:20 PM
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On October 21, 2021 at 10:20am Licensing Program Analyst (LPA) Zirbes, met with Site Supervisor, Rose Coorough to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a self-reported unusual incident report (UIR) submitted on to the Department on October 13, 2021. The UIR involved child 1 (C1) receiving an injury while playing in the licensed outdoor activity space. Upon arrival, there were 19 children and seven staff present at the facility.

During this inspection, interviews were conducted with two staff members and one child. In addition, LPA reviewed C1's file. Additional documentation related to the incident was received during this inspection. Furthermore, LPA completed a safety inspection of the facility at approximately 10:40am. There were no deficiencies noted at this time.

Due to the need to gather additional information, this investigation is being extended.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Site Supervisor Rose Coorough

SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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