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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411203
Report Date: 02/27/2020
Date Signed: 02/27/2020 02:39:38 PM

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:PACE - ANDERSON HEAD STARTFACILITY NUMBER:
197411203
ADMINISTRATOR:NICOLE JOHNSONFACILITY TYPE:
850
ADDRESS:4130 W. 154TH STREET, RM. 6TELEPHONE:
(310) 219-1173
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY:18CENSUS: 12DATE:
02/27/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Davida BrownTIME COMPLETED:
01:45 PM
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On 02/27/2020, Licensing Program Analyst (LPA) Karren Starks made an unannounced visit for an incident that occurred and was reported on 02/13/2020. LPA met with the Site Supervisor, Davida Brown who had 12 children in care along with 2 additional staff members.

Per the incident C1 and C2 were outdoors playing by the yellow apparatus began to run and ran into each other. Child 1 sustained an open wound to the forehead and Child 2 sustained a bump to the forehead. Staff was present and observed the incident occur. Staff immediately applied First Aid, called additional staff out to the area to maintain proper ratios while First Aid was being administered. The other children that were in care were redirected from the area.

Child 1's Mother was notified immediately and arrived shortly after being contacted, C1 was taken to Urgent care and returned to school on 02/19/2020. Child 2 received an ice pack and parents were contacted as well, parents did not seek medical attention for Child 2.

Based on the information obtained it does not appear this incident was the result of a Title 22 violation for Personal Rights or Lack of Care and Supervision.

The facility appeared to be in substantial compliance.

No deficiencies cited.

Copy of report and Notice of Site visit issued.
SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
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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