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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197404132
Report Date: 06/12/2024
Date Signed: 06/12/2024 10:41:03 AM


Document Has Been Signed on 06/12/2024 10:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAYCARE-NO.WEST, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:PACE - 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:
06/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Amanda VelasquezTIME COMPLETED:
10:38 AM
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On 06/12/2024 Licensing Program Analyst (LPA) Doris Whitmore and Tyra Chavies conducted an unannounced visit for the purpose of conducting a Case Management Inspection due to an incident that occurred and was reported to the Regional Office on 04/15/2024 by Grace Choi, Program Systems Coordinator. LPA Whitmore spoke to Maria Alicia Hernandez. LPA Whitmore informed about the purpose of the visit. There was a total of 35 children and 6 Staff. The UIR report stated that (C1) was playing tag with another child. When the other child came running and tagged(C1). (C1) lost his balance and fell to the ground, hitting right side of body and injuring front of his head. No bruises or scrapes, there is a red mark given ice pack observed through out the day. Parent was notified. No plans to take child to doctor.
LPA obtained a copy of the Incident Report and Personnel Report. LPA Whitmore interviewed (S1) during the interview ( S1) stated that there was another teacher outside. ( C1) was running around the structure and when (C1 ) was going out of the structure another child was coming in both children collided with one another. ( S1) stated that she sat( C1) down and applied an ice pack. Parent was notified and (C1)was observed through out the day and was ok. ( S2) was interviewed ( S2) was on her break. There was a sub sub was not present at the time of interviewing.
LPA Whitmore was unable to interview (C1) absent form school today. On 06/12/2024 Licensing Program Anayst( LPA) Doris Whitmore called the mother of (C1) Ilze Hernandez at 10:05 a.m.to follow up on the incident that occurred on 04/15/2024. Mother stated that she did not take ( C1) do the doctor because it was only a scrape. Mother stated she just kept an eye on him . Mother stated that if he had hit his head really hard she would have taken her child to the doctor. Mother stated that (C1) was fine.
There are no violations of Title 22 Regulations.
no deficiencies cited
Exit interview was conducted with Assistant Director Amanda Velasquez

Copy of this report and Notice of Site Visit issued.



SUPERVISOR'S NAME: Karren StarksTELEPHONE: (310) 740-3038
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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