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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197404132
Report Date: 02/21/2020
Date Signed: 02/21/2020 01:02:07 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: 39DATE:
02/21/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marlia Figueroa, Lead TeacherTIME COMPLETED:
01:00 PM
NARRATIVE
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On 02/21/2020, 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 two other staff members and conducted a tour of the outdoor playground. LPA inspected the play area and observed it to consist of a large, open area for open play and ball activities and an area with a play structure mounted over rubber cushioning. LPA did not observe any obstacles or hazards on the yard. Based on interviews conducted, it was revealed that on 01/28/2020, staff were positioned at various areas of the yard however facility staff failed to supervise children in the slide apparatus. As a result, child#2 had pushed child#1 causing the latter to sustain a cut above left eye. Staff#1 administered first aid and child's parent was immediately notified. As of today, child still attends the facility.

Based on the available information, it appears that the incident was the result of a Title 22 violation for lack of supervision. Facility was cited a Type B violation today, 02/21/2020. (See LIC 809-D for deficiency cited.)

An exit interview was conducted and a copy of this report, appeal rights and Notice of Site Visit were provided to 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: 02/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 BOULEVARD
FACILITY NUMBER: 197404132
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2020
Section Cited

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. This requirement it not met as evidenced by: Based on interviews conducted, it was revealed that on 01/28/2020, facility staff failed to supervise children in slide
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apparatus. As a result, child#2 had pushed child#1 causing the latter to sustain a cut above left eye. This is a Type B citation and poses an immediate health and safety risk to children in care.
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Deficinecy cleared today, 02/21/2020.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2020
LIC809 (FAS) - (06/04)
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