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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418929
Report Date: 10/09/2019
Date Signed: 10/09/2019 10:01:17 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:SUNSHINE-FAIR OAKS RANCHFACILITY NUMBER:
197418929
ADMINISTRATOR:GEORGE LOPEZFACILITY TYPE:
840
ADDRESS:26933 N. SILVERBELL LN.TELEPHONE:
(661) 424-1900
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91387
CAPACITY:165CENSUS: 0DATE:
10/09/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:George LopezTIME COMPLETED:
10:16 AM
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Licensing Program Analyst's (LPAs) Smith and Thompson-Miller met with George Lopez, Director, for a Case Management Incident inspection involving an Incident Report dated September 26, 2019. The incident occurred on September 25, 2019.

Description of the incident: Child #1 fell from monkey bars.
Child #1 was on the monkey bars, (photo taken) as she tried to get down, she fell landing on her right wrist. Staff #1 was standing nearby supervising other children when the incident occurred. A Declaration received from Staff #1. Child #1 was using the monkey bars appropriately and no other child or person caused the fall. The center followed proper protocol by calling the parent and placing ice on the wrist. It was determined that Child #1 broke her right wrist. Copy of medical report provided by center. Copy of children's roster provided.

Based on information provided and interviews conducted, further investigation is needed. An exit interview was conducted and a copy of this report was read and given to George Lopez, Director.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Suzanne SmithTELEPHONE: (661) 305-3012
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2019
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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