<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414042
Report Date: 09/05/2019
Date Signed: 09/09/2019 10:57:58 AM

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:CCRC HEAD START-SEPULVEDAFACILITY NUMBER:
197414042
ADMINISTRATOR:ARACELI GROSSMANFACILITY TYPE:
850
ADDRESS:15435 RAYEN STREETTELEPHONE:
(818) 892-0728
CITY:SEPULVEDASTATE: CAZIP CODE:
91343
CAPACITY:64CENSUS: 29DATE:
09/05/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Evelyn Zambrano & Leah SottoTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), V. Wheatley conducted a case management inspection and met with Teacher Designee, Evelyn Zambrano at 3:00PM. The director Leah Sotto arrived at 4PM.

The purpose of the inspection is to follow-up on an incident that was self-reported and submitted regarding an incident that occurred on April 9, 2019 whereby a child was injured.

LPA interviewed Staff #1 and Staff #2. Child #1 was playing in the outdoor play area and going in one direction. Another child was going in another direction and ran into Child #1. Child #1 sustained a bump on the head. The staff iced the injury immediately and called the parents. Child #1 was taken to the hospital and released the same day. The child returned to school the next day.

LPA reviewed the LIC 624 which was submitted to the department. LPA inspected the outdoor play space and did not observe any hazards. Based on information obtained, LPA's observation and interviews which were conducted there are no violations cited according to Title 22 Regulations.

Exit interview. Copy of report provided.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Veronica WheatleyTELEPHONE: (424) 301-3051
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1