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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 12:01:34 PM


Document Has Been Signed on 06/12/2024 12:01 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
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:
10:43 AM
MET WITH:Amanda Velasquez- Assistant DirectorTIME COMPLETED:
12:00 PM
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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 03/19/2024 by Grace Choi, Program Systems Coordinator. LPA spoke to Assistant Director Amanda Velasquez and informed about the purpose of the visit. There was a total of 35 children and 6 Staff. The UIR report stated that (C1) was dropped off in the morning and ran across the carpet. First aid was provided, parent was contacted at 7:07a.m. Parent did not pick (C1) up. Child remained in school the remainder of the day and was picked up at regular time. Per parent, child was not taken to the doctor, child was observed for the remainder of the day. Child returned to school on 03/19/2024.
LPA Whitmore obtained a copy of the Incident Report. and Unusual Incident/ Injury report. LPA Whitmore interviewed( C1) during the interview stated that she did not remember when she fell on the carpet. LPA Whitmore interviewed( S1) During the interview ( S1) stated that I checked her in she was the first one to come in and she put her backpack in her cubby.(C1) went to get her name tag, she started running and I said " walking feet" and that's when she tripped. When the incident occurred ( S1) was positioned by the door about to check the next child in. Parent was notified( C1) did not go to the doctor. An icepack was applied to the area. LPA'S was able to observe the area where (C1) tripped. ( S1) demonstrated how the incident occurred. Mother reason for not taking child to the doctor. Mother came back to the school to see how child was doing? The bleeding had stopped ( C1) remained in school the rest of the day child was ok. LPA'S reviewed (C1) file.
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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