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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418048
Report Date: 12/23/2020
Date Signed: 12/23/2020 05:10:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CII/WESTERN HEAD START STATE PRESCHOOLFACILITY NUMBER:
197418048
ADMINISTRATOR:MARGARITA PARRAFACILITY TYPE:
850
ADDRESS:4277 S. WESTERN AVENUETELEPHONE:
(213) 252-4380
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY:68CENSUS: DATE:
12/23/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Antonia Gutierrez, Site SupervisorTIME COMPLETED:
03:30 PM
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Due to COVID-19 and precautionary measures, Licensing Program Analyst (LPA) T. Tran delivered the Incident Report by use of via email to Antonia Gutierrez, Site Supervisor on 12/23/2020.

Licensing Program Analyst (LPA) T. Tran conducted a Case Management Incident by via telephone to follow up on a self-reported incident on 10/10/2019 regarding a child in care tripped over the string of a wooden pull toy and sustained a bump on the upper lip. On the day of the accident, there were two staff supervised five children in care. No other children involved. Parent was notified. Child had been observed by a dentist, as a result, no root fracture and no medical attention required. Based on the available information, this incident was not result in the Title 22 Regulations for Lack of Care and Supervision violation. No deficiency was cited.

Exit interview was conducted with the noted person by via telephone during which appeal rights were explained. This report along with a copy of the appeal rights will be sent to licensee by via email with a read receipt or confirmation of receipt of email, which will act as the Site Supervisor's signature.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
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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