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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409079
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:44:35 PM


Document Has Been Signed on 11/29/2022 02:44 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:
11/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Joe Vega-SmithTIME COMPLETED:
02:45 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 11/9/2022.
Description of the incident: On 11/10/2022, Palmdale Regional Office received an email from the school to report Child#1 (Age 4) collapsed on the floor while walking from the bathroom holding the assistant’s teacher’s hand. While was not responding when the teacher called his name. While on the floor, the child was breathing normally, his eyes were open and staring at the ceiling. Teacher directed the Assistant Teacher to call 911 and contact the Lead Teacher.
911 and the child’s parents were called. The parent transported the child to the hospital. The mother took the child to Kaiser Urgent Care. The child showed signs of fever and was diagnosed with a possible febrile seizure. The child was discharged around 3 p.m.
During today’s inspection visit, LPA received Child #1’s Physical Exam and ER report. Also, LPA received the IMS for Child #1.
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: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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