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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197405109
Report Date: 12/28/2022
Date Signed: 12/28/2022 03:06:20 PM


Document Has Been Signed on 12/28/2022 03:06 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:CONGREGATION BETH SHALOMFACILITY NUMBER:
197405109
ADMINISTRATOR:CAROL BLOOMFACILITY TYPE:
850
ADDRESS:21430 CENTRE POINTE PARKWAYTELEPHONE:
(661) 254-2411
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY:96CENSUS: 10DATE:
12/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Carol Bloom, DirectorTIME COMPLETED:
12:30 PM
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On 12/28/22 at 10:15 a.m., Licensing Program Analyst (LPAs) Joselito L. Del Mundo and Esequiel Rodriguez conducted a case management inspection at the Facility and met Licensee Carol Bloom. The purpose for the inspection was to follow-up on an Unusual Incident Report (UIR) reported on 12/22/22 to the Department. The incident indicates that C-1 sustained a right leg fracture. See Confidential Names list (LIC 811) dated 12/28/22.

Per Licensee, there were twenty three (23) children playing outside and were properly supervised by three (3) staff (S-1, S-2 and S-3). Licensee indicated that C-1 while playing outside on the slide, was sliding down, apparently landed wrong and sustained the injury. Per Licensee, the incident could not be prevented from happening even though C-1 landed on a rubberized mats. C-1, immediately, received basic first aid by applying ice on both sides of C-1s lower leg and the parents were immediately notified of the incident. The parents took the child to the Emergency Room. Later, the Center was informed that C-1 sustained a right leg fracture. C-1 was observed to be in good health and thriving in the environment.

An incident report was submitted to the Department in a timely manner. Per Licensee, the incident did happened but it did not happened because of neglect or lack of supervision.

The LPAs obtained copies of Childrens Roster, and Personnel Report.

At the time of this inspection the LPAs observed no signs of abuse or neglect. The LPAs did not observed any evidence of wrong doing, the Center was clean, safe, secure and orderly.

Copy of this report, LIC 811, and notice of site visit was provided to licensee. At this time, no further action is required.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Joselito DelMundoTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
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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