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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414043
Report Date: 09/13/2019
Date Signed: 09/13/2019 03:57:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:CCRC HEAD START-MIGUEL MONTESFACILITY NUMBER:
197414043
ADMINISTRATOR:NEREYDA LEVINGSFACILITY TYPE:
850
ADDRESS:10675 TELFAIR STREETTELEPHONE:
(818) 834-2358
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY:39CENSUS: 18DATE:
09/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nereyda Levings, DirectorTIME COMPLETED:
02:00 PM
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On 09/13/2019 at 9:45 a.m., Mariela Ramon, Licensing Program Manager (LPM) and Jesse Sims, Licensing Program Analyst (LPA) met with Nereyda Levings, Director for the purpose of following up on an unusual incident that occurred at the facility on 09/11/19, and it was reported the same day to the Department. The incident indicates child #2 bit child #1 while children were lining up to wash their hands in the classroom sink.
Pictures of the facility were taken during this inspection.

LPM and LPA conducted interviews related to the incident with children and staff. Children and staff files were reviewed, Children and staff files were complete.

At this time, this incident requires additional follow up. Director was provided with a copy of this report.

An exit interview was conducted with facility Director, a copy of this report and Notice of Site Visit were provided to Director.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Jesse SimsTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019
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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