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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417540
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:25:18 PM


Document Has Been Signed on 04/19/2022 02:25 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:VILLAGE TREE PRESCHOOLFACILITY NUMBER:
197417540
ADMINISTRATOR:CINDY RENDEROS CONTRERASFACILITY TYPE:
850
ADDRESS:4235 DUQUESNE AVENUETELEPHONE:
(310) 204-5458
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:45CENSUS: 35DATE:
04/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:CINDY RENDEROS CONTRERASTIME COMPLETED:
02:35 PM
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On 4/19/2022, Licensing Program Analyst (LPA) Loyce Phillips, conducted a case management inspection to follow up on an Unusual Incident reported to the department by telephone on 3/18/2022. LPA met with Director, Cindy Renderos Contreras and toured the facility and took a census of the children. Upon arrival, there were 35 children and 7 staff present today at the facility.

Description of the incident: On 3/16/2022 at 11:30am, C1 was playing outside on the playground with his class. C1 went down the slide and landed on his wrist. The staff member gave C1 an ice pack and checked his hand for movement. C1 parents were called and parent picked child up at 12:20pm. Parent took C1 to urgent on 3/16/2022 and an X-ray was taken, but no fracture was confirmed. On 3/18/2022 C1 was referred to a Pediatric Ortho and confirmed a fracture to his lower arm. C1 will wear a full arm cast for 5 weeks.

Based on the information obtained, interviews conducted and LPA observation. Staff was providing care and supervision when C1 fell on his arm playing on the slide. As of 4/19/2022, C1 full arm cast has been removed and C1 is back to normal activities. C1 falling on his arm was an accident; therefore, no Title 22 violations have occurred and no deficiencies cited. Director was encouraged to continue to report unusual incidents that occur in the facility in a timely manner.

An exit interview was conducted, a copy of this report and notice of site visit was provided to Director, Cindy Renderos Contreras.

SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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