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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414043
Report Date: 03/08/2023
Date Signed: 03/08/2023 11:04:27 AM


Document Has Been Signed on 03/08/2023 11:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:CCRC HEAD START-MIGUEL MONTESFACILITY NUMBER:
197414043
ADMINISTRATOR:HERMINEH AZIZIANFACILITY TYPE:
850
ADDRESS:10675 TELFAIR STREETTELEPHONE:
(818) 834-2358
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY:39CENSUS: 22DATE:
03/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Sandy Zarrabal - Teacher DesigneeTIME COMPLETED:
10:59 AM
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
On 03/8/2023 Licensing Program Analyst (LPA) Ortega arrived at the Facility to conduct a Case Management Inspection for an Unusual Incident Report (UIR) received at the Palmdale Regional Office. LPA met with Sandy Zarrabal, Teacher Designee and toured the facility according to the facility sketch. At the time of arrival LPA observed 22 children in care and five staff providing care and supervision.

The purpose of this case management inspection is to follow up on a self reported unusual incident report (UIR) submitted to the Department on 2/22/2023. The unusual incident report was regarding an injury to Child #1 on the outdoor play structure.

During this inspection LPA conducted interviews with staff and completed a file review. In addition, LPA completed a safety inspection of the facility's out door play area. In addition, during the inspection, LPA obtained copies of documentation related to the case management incident.

Facility followed protocol, three staff were providing care and supervision during the incident. According to interviews conducted Child #1 was running and lost his balance causing him to fall and get injured. Parent was notified in a timely manner and UIR was reporting within the time frame required. Child #1 was has resumed normal activities.

No deficiencies will be cited today. A notice of site visit was provided and requested to be posted for 30 days. An exit interview was conducted, a copy of this report, notice of site visit and appeal rights were provided to facility.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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