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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403329
Report Date: 03/11/2022
Date Signed: 03/11/2022 01:32:57 PM


Document Has Been Signed on 03/11/2022 01:32 PM - 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:CROSSWIND COMMUNITY CHURCH-ADVENTURELAND P.S.FACILITY NUMBER:
197403329
ADMINISTRATOR:JIMENEZ, MISTYFACILITY TYPE:
850
ADDRESS:41337 10TH STREET WESTTELEPHONE:
(661) 272-4903
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:73CENSUS: 25DATE:
03/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Misty JimenezTIME COMPLETED:
01:40 PM
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On 03/11/22 at 10:30 AM Licensing Program Analyst (LPA) Leandra Dolliole met with Director Misty Jimenez to conduct an unannounced case management inspection to follow-up on a self- reported unusual incident report submitted by the facility on 02-28-22. Upon arrival, LPA observed 25 children and 3 staff members.

Description of incident: On 02-25-22 at approximately 11AM Child #1 was crawling under a picnic table during outside play and lost balance. Child # 1 fell forward causing a laceration to the top left eyebrow.

Based on the information gathered from observations, record review and interviews conducted with the children, staff, assistant director and director additional follow up is needed.

Exit interview was conducted, report was read, and a copy of this report was given to the facility director along with the notice of site visit.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Leandra DollioleTELEPHONE: (619) 202-3380
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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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