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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197404132
Report Date: 08/29/2019
Date Signed: 08/29/2019 03:00:09 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:PACE HEAD START - WEST BOULEVARDFACILITY NUMBER:
197404132
ADMINISTRATOR:SILVA DE LA ROSAFACILITY TYPE:
850
ADDRESS:1809 WEST BLVD.TELEPHONE:
(323) 954-8099
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:68CENSUS: 40DATE:
08/29/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marlia Figueroa, Lead Teacher and Ruzanna Davtian, Regional Site DirectorTIME COMPLETED:
03:00 PM
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On 08/29/2019 at 12:00 pm, Licensing Program Analyst (LPA) Sabrina Martinez conducted an unannounced inspection at Pace Head Start-West Boulevard located at 1809 West Blvd., Los Angeles, CA 90019 for the purpose of following up on an unusual incident that occurred at the facility on 05/24/2019. The self reported unusual incident was received by the El Segundo Regional Child Care Office via phone call on 05/28/2019.

On 06/18/2019, LPA attempted to conduct a visit however, the facility was closed from 06/11/2019-08/12/2019 for the summer break. LPA met with Marlia Figueroa, lead teacher, and discussed the purpose of today's visit. At around 1:00 pm, Ruzanna Davtian, Regional Site Director, also arrived at the facility.

According to the report that the Department received, on 05/24/2019 around 8:40 am two children were playing outside. One child pulled the other child's finger. The finger was red, ice pack was applied. The parent was notified that child stated it hurts. The school was notified on 05/24/2019 that child was taken to ER and finger was fractured.

During today's inspection, LPA conducted an interview and obtained written declaration from staff#1, conducted a telephonic interview with child#1's parent and conducted a review of records and obtained copies of the sign in and sign out sheet dated 05/24/2019 and child #1's medical discharge summary papers.

At this time, further investigation is needed.

An exit interview was conducted and a copy of this report was provided to Ruzanna Davtian, Regional Site Director.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2019
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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