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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409079
Report Date: 08/31/2021
Date Signed: 08/31/2021 12:21:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:PALMDALE SCHOOL DISTRICT-TUMBLEWEED HEAD STARTFACILITY NUMBER:
197409079
ADMINISTRATOR:LEBETSAMER, DONNAFACILITY TYPE:
850
ADDRESS:1100 EAST AVENUE R-4TELEPHONE:
(661) 273-4710
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:200CENSUS: 12DATE:
08/31/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jacqueline Valladares TIME COMPLETED:
12:30 PM
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On 08-31-21, Licensing Program Analyst (LPA) Lady King-Lewis arrived a the facility to conduct a Case Management incident inspection. The purpose of the case management visit was to gather additional information for a self reported Unusual Incident Report submitted by the facility on 08-25-21.

During the visit, LPA took a census of the children present, and met with child 1 teacher in room 5, assistance teachers, interviewed children and received copy of the attendance sheet for August 2021.

Further information is needed.

An exit interview was conducted, a copy of this report, and Notice of Site visit given to Joe Vega-Smith. LPA informed to be post the Notice of Site Visit for 30 days.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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