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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409079
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:33:37 PM


Document Has Been Signed on 11/03/2022 02:33 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:PALMDALE SCHOOL DISTRICT-TUMBLEWEED HEAD STARTFACILITY NUMBER:
197409079
ADMINISTRATOR:DR. MELANIE CULVERFACILITY TYPE:
850
ADDRESS:1100 EAST AVENUE R-4TELEPHONE:
(661) 267-9934
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:200CENSUS: DATE:
11/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Joe Vega-SmithTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Carol Heath met with the School Readiness Coordinator (SRC), Joe Vega-Smith for a Case Management Incident inspection involving an Incident dated 10/4/2022.
Description of the incident: On 10/4/2022, Palmdale Regional Office received an email from the school to report Child#1 had seizure activity during class hours. 911, the Foster mother, and the ECE nurse were called and Child #1 was transported to AV hospital.
LPA received child#1’s Emergency information, Physical Exam, and IZ record. LPA received a copy of the Facility Roster. LPA interviewed the foster mother. During today's inspection visit,
LPA spoke with the Nurse in the Office and the classroom teacher Ana Rauda. Pre Joe Vega-Smith (SRC), the child is a foster child and came from Wisconsin. There is no history of seizures. In addition, Child #1’s Bio mom got custody of the child and moved to Kentucky. Child #1’s last day was 11/1/2022.
Based on the information gathered and interviews, staff followed their reporting policy and procedure. No citation was issued on this date.
An exit interview was conducted and a copy of the report was read and provided to the School Readiness Coordinator, Joe Vega-Smith.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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