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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493687
Report Date: 06/17/2021
Date Signed: 06/17/2021 03:58:57 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:CHALK OF WESTWOODFACILITY NUMBER:
197493687
ADMINISTRATOR:NICOLE BROZKAFACILITY TYPE:
850
ADDRESS:2028 WESTWOOD BOULEVARDTELEPHONE:
(310) 446-5400
CITY:LOS ANGELESSTATE: CAZIP CODE:
90025
CAPACITY:71CENSUS: 36DATE:
06/17/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Mary Jane Escorpiso, Interim Director TIME COMPLETED:
04:03 PM
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On 06/17/2021 at 2:35pm, Licensing Program Analyst (LPA) Denise Miranda conducted an unannounced case management inspection at Chalk of Westwood, located at 2028 Westwood Blvd, Los Angeles, CA 90025 for the purpose of following up on the unusual incident that was self reported by the facility. The El Segundo Child Care Regional Office received the report on 05/27/2021.

Upon arrival, LPA met with Ms. Cindy Salaues, The Health and Safety Director and Ms. Mary Jane Escorpiso, Interim Director and discussed the purpose of the visit.

According to the incident report, on 5/26/2021, child#1 was playing on the play yard and was coming down the cube climber and fall landing on her right arm.
After the incident, facility applied ice and put on a splint on child’s right arm. Chid’s father took child#1 child to the urgent, and a hard cast was placed on child'#1 arm.

During this inspection, LPA conducted interviews with facility staff and children, reviewed staff#1 and child's records and obtained documents. Staff#1 was not present during this inspection.

At this time, further investigation is needed.

An exit interview was conducted and a copy of this report along with the Notice of Site Visit were provided to Mary Jane Escorpiso, Interim Director.
SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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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