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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419963
Report Date: 11/13/2019
Date Signed: 11/13/2019 03:56:26 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:YMCA OF METRO LA CALABASH CHARTER ACADEMYFACILITY NUMBER:
197419963
ADMINISTRATOR:RACHEL HERNANDEZFACILITY TYPE:
840
ADDRESS:23055 EUGENE STREETTELEPHONE:
(818) 668-2611
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:75CENSUS: 45DATE:
11/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Rachel HernandezTIME COMPLETED:
04:15 PM
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On 11/13/19 at 2:10 PM, Licensing Program Analyst (LPA) Angelica Ramirez arrived at YMCA of Metro LA Calabash Charter Academy for the purpose of following up on the unusual incident that occurred at the facility on 9/3/19. The El Segundo Regional Child Care Office received the report via phone call on 9/5/19. LPA met with Director Rachel Hernandez.

According to the report, on 9/3/19 at approximately 4:50 PM, children were transitioning to the carpet when Child #2 felt Child #1 was invading her space and kicked Child #1. Child #1 fell backwards and hit his head. Staff #1 and #2 observed the incident and assisted Child #1, provided first aid and contacted parents.

During this inspection, LPA conducted interviews with facility staff and children. LPA conducted a tour of the area where the incident occurred, reviewed children's files, and obtained a copy of the facility roster. LPA requested copies of the facility sign in sheets for the 9/3/19 as they are not kept on site.

Based on the information obtained throughout the course of the investigation, at this time it does not appear that the incident was a result of a Title 22 violation.

Facility staff provided proper care and supervision during the time of the incident. The facility followed Title 22 Regulations in the care and supervision of the children and reporting the incident to the Community Care Licensing Division. LPA provided consultation with the director regarding time frames for reporting incidents, see LIC9102.

An exit interview was conducted and a copy of this report along with the Notice of Site Visit were provided to Rachel Hernandez, Center Director.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Angelica RamirezTELEPHONE: (424) 301-3071
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2019
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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