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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419730
Report Date: 12/29/2021
Date Signed: 12/29/2021 02:29:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:LEARNING TREE BEFORE AND AFTER SCHOOL CAREFACILITY NUMBER:
197419730
ADMINISTRATOR:MARCELLINE, NIORAM & AARONFACILITY TYPE:
840
ADDRESS:17873 SIERRA HIGHWAYTELEPHONE:
(661) 877-2130
CITY:SANTA CLARITASTATE: CAZIP CODE:
91351
CAPACITY:52CENSUS: 31DATE:
12/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Aaron Marcelline, licenseeTIME COMPLETED:
02:44 PM
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On 12-29-21, Licensing Program Analyst (LPA) Lady King-Lewis arrived at the facility to conduct a case management inspection . The purpose of the case management visit was to follow-up on a self reported Unusual Incident Report submitted by the facility on 12-03-21.

During the visit, LPA took a census of the children present, and met with Center licensee Aaron Marcelline to discuss the reported incident. During the visit, LPA spoke with child 1, 2, 3, and licensee and green room teacher where the incident happen. LPA took photo of school roster, staff roster, and sign in sheet for the day of the incident. LPA is asking for staff sign in sheet for the date of the incident.

Further investigation is needed.

An exit interview was conducted, a notice of site visit was given to be posted for 30 days.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
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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