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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407441
Report Date: 10/15/2019
Date Signed: 10/15/2019 11:18:14 AM

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:HALSEY SCHOOLS, INCORPORATEDFACILITY NUMBER:
197407441
ADMINISTRATOR:ELENITA MERCERFACILITY TYPE:
830
ADDRESS:5319 COMERCIO WAYTELEPHONE:
(818) 835-1629
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:56CENSUS: 34DATE:
10/15/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Jennifer Nann, Administrative DirectorTIME COMPLETED:
11:30 AM
NARRATIVE
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On 10/15/2019 at 08:50 am, Licensing Program Analyst (LPA) Sabrina Martinez arrived at Halsey Schools located at 5319 Comercio Way, Woodland Hills, CA 91364 for the purpose of following up on the unusual incident that occurred at the facility on 09/16/2019. The El Segundo received the Unusual Incident/Injury Report (UIR) via fax on 10/01/2019. LPA met with Jennifer Nann, Administrative Director, and discussed the purpose of the visit.

According to the report that the Department received, on 09/16/2019 at 6:17 pm, child#1 was in the main playroom when he was walking and tripped over a few toys. The child fell and hit the corner of a toy shelf. Staff#1 helped the child up and noticed blood. The staff picked up the child and inspected to locate where the blood was coming from. The staff applied pressure to the wound and contacted the child's parent. The child's cut didn't require stitches however liquid glue was used to close the cut. The child returned to the facility on 09/17/2019.

During this inspection, LPA conducted an interview with facility staff. LPA also attempted to conduct an interview with the child involved and the child's parent. LPA also reviewed child's records and obtained a copy of the sign in and sign out sheet dated 09/16/19. Based on the information gathered throughout the course of the investigation, it does not appear that the incident was a result of a lack of care and supervision. Facility staff witnessed the incident, acted immediately and first aid was administered. Child's parents were also immediately notified of the incident. However, licensee failed to report the incident to the Department as required within 24 hours and written follow-up within seven days. Licensee will be cited for failure to report incident to licensing in a timely manner in compliance with the requirements of Title 22 Division 12; Section 102416.2. See LIC 809-D for citation.

An exit interview was conducted and a copy of this report, appeal rights and the Notice of Site Visit were provided to Jennifer Nann, Administrative Director.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
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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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: HALSEY SCHOOLS, INCORPORATED
FACILITY NUMBER: 197407441
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2019
Section Cited

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Reporting Requirements....a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported
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shall include the following: (B) Any injury to any child that requires medical treatment. This requirement is not met as evidenced by: Licensee failed to report Unusual Incident which occurred on 09/16/19 as required by the Title 22 Regulations in a timely manner. This is a Type B citation and poses a potential health and safety risk to children in care.
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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: 10/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2019
LIC809 (FAS) - (06/04)
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