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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197404132
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:09:14 PM

Document Has Been Signed on 10/16/2024 02:09 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/
DIRECTOR:		SILVA DE LA ROSAFACILITY TYPE:
850
ADDRESS:1809 WEST BLVD.TELEPHONE:
(323) 954-8099
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 68TOTAL ENROLLED CHILDREN: 69CENSUS: 34DATE:
10/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Lashaye Davis- Regional Site DirectorTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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On 10/16/2024 at 8:30 a.m. Licensing Program Analyst (LPA)Doris Whitmore conducted an unannounced visit for conducting a Case Management Inspection due to an incident that occurred on 09/19/2024 and was reported to the Regional Office. LPA met with Lashaye Davis, Regional Site Director and informed the nature of the visit. LPA observed 34 Children in care with proper teacher/child ratios observed. There was a total of 6 staff.
According to the Unusual Incident/ Injury Report, during choice time at approximately 10:15a.m. C1 and C2 were in the house area playing. C2 picked up a toy metal ladle and threw it at C1, hitting him on the right side of his forehead just above his eyebrow resulting in an approximately 1-inch gash. Cut on his forehead. Teacher applied pressure to the wound, stopping the bleeding, clean it, and applied bandage. An icepack was applied, and parent was notified via phone call from Site Lead Teacher. Parent picked child up at 10:20 a.m. Mother was given accident report and head injury form.

During the investigation LPA Whitmore was informed and made aware of that on the LIC 624 and the telephone incident report that C2 was not the child that hit C1. Regional Site Director Lashaye Davis explained to LPA Whitmore. LPA Whitmore also spoke to S1 and she clarified that it was a total of three children in the house keeping area that were standing side by side and that C3 threw the metal ladle(spoon). LPA Whitmore interviewed staff and children. During the investigation S1 was able to show LPA Whitmore the area where the incident took place. LPA Whitmore took a picture of the metal ladle. In the office the Regional Site Director explained to LPA Whitmore and that the metal ladie(spoon) was removed from the classroom. LPA Whitmore observed the metal ladie(spoon) and other metal pretend dishes in the office. C3 was absent and could not be interviewed today.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 BOULEVARD
FACILITY NUMBER: 197404132
VISIT DATE: 10/16/2024
NARRATIVE
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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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
L.A. DAYCARE-NO.WEST, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PACE - WEST BOULEVARD
FACILITY NUMBER: 197404132
VISIT DATE: 10/16/2024
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LPA obtained a copy of Doctor’s Note, Head Injury Precaution Sheet, Accident/ Incident Report, & Personnel Report, Monthly Attendance, Roster& Request for Behavior Support LPA conducted a record review of three files.

Based on the interviews and the documents obtained the incident needs further investigation. An exit interview was conducted with Regional Site Director Lashaye Davis. Copy of this report, Notice of Site Visit, & Appeal Rights issued.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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