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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197404676
Report Date: 10/09/2019
Date Signed: 10/09/2019 03:28:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:PALMDALE SCHOOL DISTRICT-MESQUITE SCHOOL HEAD STARFACILITY NUMBER:
197404676
ADMINISTRATOR:LEBETSAMER, DONNAFACILITY TYPE:
850
ADDRESS:37622 43RD ST. EASTTELEPHONE:
(661) 273-4710
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY:44CENSUS: 13DATE:
10/09/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Lisa Fowler, Assistant AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst's (LPAs) Thompson-Miller and Smith met with Lisa Fowler, Assistant Administrator for a Case Management Incident inspection involving an Incident Report dated 09/27/19. The incident occurred on September 26, 2019.

Description of the incident: Child #1 had a seizure. Child #1 arrived at the school, a wellness check was given and appeared tired. Staff #1 observed Child #1 lethargic, his head was twirling and couldn't hold his head up. Staff followed proper protocol, contacted parent and called emergency medical service (911). It was determined Child #1 had a seizure and a copy of the medical report was provided.

Based on the information obtained during the inspection, there appeared to be no violations of Title 22 Regulations pertaining to the reported incident. Exit interview conducted and a copy of report provided to Lisa Fowler, Assistant Administrator on this date.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Linda Thompson-MillerTELEPHONE: (661) 568-8186
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2019
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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