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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419009
Report Date: 04/04/2022
Date Signed: 04/04/2022 12:04:21 PM


Document Has Been Signed on 04/04/2022 12:04 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:CII/HARVARD HEAD STARTFACILITY NUMBER:
197419009
ADMINISTRATOR:ANA PANIAGUAFACILITY TYPE:
850
ADDRESS:1506 W. 61ST STREETTELEPHONE:
(213) 385-5100
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:35CENSUS: 23DATE:
04/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Debbie RivasTIME COMPLETED:
12:00 PM
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On 4/4/2022, Licensing Program Analyst (LPA) Lillian Casillas conducted an unannounced Case Management – Incident inspection for the purpose of following up on an Unusual Incident Report (UIR) submitted on 3/28/2022. LPA met with Debbie Rivas, Site Supervisor, who toured LPA through the inside and outside of the facility. LPA observed 23 children in care and 5 staff.

According to the UIR, on 3/23/2022, Staff 1 (S1) covered Child 1's (C1) mouth to quiet C1 during nap time. Staff 3 overhead C1 screaming and a muffled sound, but did not observe S1 cover the child's mouth.



During the investigation, LPA interviewed Site Supervisor, Staff 2, C1, and Child 2. LPA obtained the children’s roster (LIC9040), personnel report (LIC500), and a copy of the 4110 Family Service History report for C1.

At this time, further investigation is needed. An exit interview was conducted and a copy of this report (LIC 809) and Notice of Site Visit were provided to Site Supervisor, Debbie Rivas.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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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