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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414609
Report Date: 06/21/2021
Date Signed: 06/21/2021 05:03:23 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:JOHN ADAMS CHILD DEVELOPMENT CENTERFACILITY NUMBER:
197414609
ADMINISTRATOR:SUSAN SAMARGEFACILITY TYPE:
850
ADDRESS:2320 17TH STREETTELEPHONE:
(310) 399-5865
CITY:SANTA MONICASTATE: CAZIP CODE:
90405
CAPACITY:65CENSUS: 0DATE:
06/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Reham DebashTIME COMPLETED:
04:50 PM
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On 06/21/2021 at 11:06am, Licensing Program Analyst (LPA) Lillian Casillas conducted a Case Management- Incident tele-conference inspection for the purpose of following up on the Unusual Incident Report (UIR) submitted on 05/12/2021. LPA met with Reham Debash, Assistant Director, and discussed the purpose of the visit. This facility closed on 06/11/2021 and will reopen on 08/19/2021.

According to the UIR, Staff 1 (S1) notified Ms. Debash that Parent 1 (P1) stated that Child 1 (C1) was afraid to go to preschool because Staff 2 (S2) hurt him. P1 told S1 that S2 shoved C1 and that P1 overhead C1 crying while S2 changed his diaper.

During the investigation, LPA conducted interviews with the Assistant Director, S1, S2, and P1. LPA also reviewed the UIR and the facility's history.

Based on interviews and record review, the incident was not deemed a result of a Title 22 violation.

An exit interview was conducted on 06/21/2021 at 04:50pm and a copy of this report along with the Notice of Site Visit were provided to Reham Debash, Assistant Director. LPA Casillas requested an email reply from the Ms. Debash in lieu of a signature.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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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