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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418366
Report Date: 03/10/2025
Date Signed: 03/10/2025 03:50:46 PM

Document Has Been Signed on 03/10/2025 03:50 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:WOODY'S CLUBHOUSEFACILITY NUMBER:
197418366
ADMINISTRATOR/
DIRECTOR:		KATHY VIRAMONTESFACILITY TYPE:
840
ADDRESS:22201 SAN MIGUEL STREETTELEPHONE:
(805) 660-6097
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY: 200TOTAL ENROLLED CHILDREN: 150CENSUS: 105DATE:
03/10/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Kristina Golem, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an unannounced case management inspection due to an incident that occurred on 2/7/2025. LPA arrived at the facility at 2:00 PM and met with Licensee,Kristina Golem, who guided LPA on a tour of the facility. There were 105 children and 13 staff present upon arrival.

The incident that occurred on 02/07/2024, was reported to the Department on 02/13/2024, via telephone. The facility reported the Unusual Incident to the Department within the required 24 hours of occurrence.

Description of the incident: C1 was playing on the play structure on the kindergraten yard and fell and landed on his wrist. Three staff witnessed the incident and provided first aid to C1. Mom was called and picked up C1 and took him to urgent care. C1 had broke his wrist and was provided with a temporary cast, a doctors note and returned to the program the next day.

LPA interviewed S1 who was closest to the C1 and who went over and provided an ice pack to C1. S1 saw the incident occur but could not reach the child in time. Two additional staff saw the incident as well.

Based on interviews, and statements, it was determined nothing could have been done to prevent Child #1 from falling and obtaining an injury.

No deficiencies were cited during today's visit. Notice of site visit must be posted for 30 days.

Exit interview was conducted and report was giving to Licensee, Kristina Golem.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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