<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197404132
Report Date: 02/18/2020
Date Signed: 02/18/2020 02:50:33 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: 25DATE:
02/18/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marlia Figueroa, Lead TeacherTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 02/18/2020 at 12:30 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 the self reported unusual incident that occurred at the facility on 01/28/2020. The report was received via phone call on 01/29/2020 and the Unusual Incident/Injury Report (UIR) (LIC 624) was faxed to the El Segundo Child Care Regional Office on 01/31/2020.

According to the Unusual Incident/Injury Report (UIR) that the Department received, on 01/28/2020 at around 4:35 pm, child#1 was pushed by child#2 and child#1 slipped on the stairs. The child hit left eye and resulted in a cut on the left eyebrow. Staff#1 notified child's parent and was advised to take the child to the doctor.

During this inspection, LPA conducted an interview with facility staff and child involved in the incident.

At this time, further investigation is needed.

An exit interview was conducted with Marlia Figueroa, Lead Teacher.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1