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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419383
Report Date: 10/28/2021
Date Signed: 10/28/2021 01:29:50 PM

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:LWIN FAMILY CHILD CAREFACILITY NUMBER:
197419383
ADMINISTRATOR:LWIN, SHALLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 237-5822
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:14CENSUS: 9DATE:
10/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:SHALLY LWINTIME COMPLETED:
01:40 PM
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On 10/28/2021, 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 8/6/2021. LPA met with Licensee, Shally Lwin and toured the facility and took a census of the children. Upon arrival, there were 9 children and 2 staff present today at the facility.

Description of the incident: On 8/4/2021 at 9:20am the children were playing outside in the play area. C1 was playing with C2 in the playhouse. C2 went in the playhouse through the door and C1 went in the playhouse through the window. C1 fell and hurt her elbow while entering through the window. Licensee asked C1 if she was okay and asked C1 to raise her arm. C1 could raise her arm but not fully. Licensee applied ice and called the parents to pick-up C1. Parent took C1 to the hospital on 8/4/2021 for an examine and observation. C1 returned to the hospital on 8/5/2021 and medical provider put a cast on C1's arm.

Based on the information obtained, interviews conducted and LPA's observation. Licensee was providing care and supervision when C1 fell on her arm. C1 falling on her arm was an accident; therefore, no Title 22 violations have occurred and no deficiencies cited. Licensee 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 Licensee, Shally Lwin.
SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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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