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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197404132
Report Date: 09/09/2019
Date Signed: 09/10/2019 09:57:04 AM

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: 35DATE:
09/09/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ruzanna Davtian, Regional Site DirectorTIME COMPLETED:
03:15 PM
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On 09/09/2019 at 01:30 pm, Licensing Program Analyst (LPA) Sabrina Martinez arrived at PACE Head Start-West Boulevard for the purpose of delivering the investigation findings for the the self reported unusual incident that occurred at the facility on 05/24/2019. LPA met with Ruzanna Davtian, Regional Site Director, and discussed the purpose of the visit.

This agency has investigated the unusual incident which includes observations at the facility, interview with relevant parties, and review of records. During this investigation, it was revealed that on 05/24/2019, there were two teachers in the outdoor playground with 14 children when the incident occurred, and staff observed the incident. Facility staff applied ice pack and notified the parent of the child's injury.

Based upon evidences obtained during the course of this investigation, there is no evidence establishing that the injury was the result of lack of care and/or supervision and is not a violation of Title 22 Regulation.

An exit interview was conducted and a copy of this report along with the Notice of Site Visit were 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: 09/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2019
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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