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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419506
Report Date: 09/12/2019
Date Signed: 09/12/2019 02:46:13 PM

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- PICO CANYONFACILITY NUMBER:
197419506
ADMINISTRATOR:MOWRY, LAURENFACILITY TYPE:
840
ADDRESS:25255 PICO CANYON ROADTELEPHONE:
(661) 288-7983
CITY:STEVENSON RANCSTATE: CAZIP CODE:
91381
CAPACITY:105CENSUS: 24DATE:
09/12/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Lauren MowryTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Neal met with Facility Administrator, Lauren Mowry and conducted a Case Management inspection to follow-up on an Unusual Incident Report received on 9/11/2019. This incident was self-reported by the center.

Description of Incident: On 9/10/2019, at approximately 4:20pm, Child #1 was playing soccer on the playground and got hit by the ball in the stomach. Staff #1 checked to see if Child #1 was okay and while walking Child #1 over to rest, Child #1 fell to the ground crying, with clinched fists, then passed out. Child #1 was unconscious for approximately 30-45 seconds during which time 911 was called. Parents were notified and Child #1 was taken to the hospital via ambulance. Per staff there were no loose tripping hazards in the playground area.

During today's inspection, LPA interviewed staff present during the incident and Child #1, who was present at the center. Child's file was reviewed. Administrator received a copy of School Release Form noting Child #1's permission to return to school. Based on review of the actions taken by the facility, interviews conducted and other information obtained, no additional follow up will be required at this time.

No deficiencies were cited during today's inspection.
Notice of site visit was given to be posted for 30 days.
Exit interview was conducted and a copy of this report was provided to the administrator.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Jazelle NealTELEPHONE: (661) 568-8945
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2019
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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