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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411203
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:53:43 PM


Document Has Been Signed on 08/22/2024 03:53 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
L.A. DAYCARE-NO.WEST, 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: 4DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Sanji Peiries- Site LeadTIME COMPLETED:
03:53 PM
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On 8/22/2024 Licensing Program Analyst (LPA) Doris Whitmore conducted an unannounced visit for the purpose of conducting a Case Management Inspection due to an incident that occurred and was reported to the Regional Office on 05/30/2024 by Grace Choi, Program Systems Coordinator. LPA spoke to the Site Lead Sanji Peiries and was informed about the purpose of the visit. There was a total of 4 children and 4 Staff. The UIR report stated that (C1) on 05/30/2024 around 9:30 a.m., another child pushed (c1) and he hit his head on wall by block area. Teacher examined the injury and saw that there was no injury or broken skin. Teacher placed icepack on injury. Parent was notified and left child at school to finish that day. At this time, parent has declined to take the child to the hospital.
A copy of the Accident Report and Head injury report will be emailed. LPA Whitmore interviewed (S1) and (S2). At the time of the Case Management Inspection (C1) is in the morning class and was not present. Site Lead called the mom. LPA Whitmore spoke to the mom regarding the incident that took place 05/30/2024. Parent stated that she did not remember the incident. LPA Whitmore asked the mom if she could interview ( C1) on the phone mother stated No. There were no deficiencies.
Exit interview was conducted with Site Lead Sanji Peiries. Copy of this report along with Site Visit was issued.
SUPERVISOR'S NAME: Karren StarksTELEPHONE: (310) 740-3038
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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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