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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492873
Report Date: 10/24/2019
Date Signed: 10/24/2019 04:33:20 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:LEARNING TREE PRESCHOOL, THEFACILITY NUMBER:
197492873
ADMINISTRATOR:CHAVEZ, MATTHEWFACILITY TYPE:
850
ADDRESS:39625 20TH STREET WESTTELEPHONE:
(661) 266-4900
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:86CENSUS: 50DATE:
10/24/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Sheri Potter, TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Victoria Hunt met with Sheri Potter Site Director, for a Case Management inspection involving an Unusual Incident Report (UIR) received by fax on 10/21/19. The Site Director also, contacted the department via telephone to report the incident on 10/21/19. The Unusual Incident was reported timely to the Palmdale Regional Office. Upon arrival, LPA toured the facility and observed 50 children and 7 staff present during today’s visit.

Description of the incident: The incident occurred on 10/21/19 at approximately 10:09 am, as children were playing outside in the playground area, and child #1 fell on the sidewalk resulting in a broken right arm. Staff promptly administered aid to child #1, by attending to the arm of the child. Staff #1, contacted the director immediately and child #1 was brought to the office. The paramedics were contacted immediately following the incident along with child’s parent. This incident was caught on video surveillance. During today’s inspection LPA viewed the video recording, reviewed the file/record of child #1, took photo's of play yard/ground and conducted interviews with staff.

It appears that at the time of the incident staff were in ratio and capacity. Based on the information obtained, it does not appear that a violation of Title 22 Regulations occurred due to the incident being an accident.

No citations are being issued on this date. An exit interview was conducted and a copy of this report was read and provided to the Assistant Director on 10/24/19.




SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Victoria HuntTELEPHONE: (661) 568-8930
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2019
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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