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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493784
Report Date: 09/11/2019
Date Signed: 09/18/2019 09:53:45 AM

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:KID'S CLUB PROGRAMSFACILITY NUMBER:
197493784
ADMINISTRATOR:ROBERTS, TONYFACILITY TYPE:
840
ADDRESS:23838 KITTRIDGE STREETTELEPHONE:
(818) 591-2582
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:52CENSUS: 13DATE:
09/11/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Tony Roberts - AdministratorTIME COMPLETED:
03:45 PM
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On 9/11/19, Licensing Program Analyst (LPA) Helen Estrella conducted a subsequent case management inspection to the school age center. Upon arrival, LPA met with the Administrator Tony Roberts and informed him the nature of the visit. There was a total census of 13 children in care with 2 staff, and the licensee during today's inspection. LPA was guided of tour of the facility (inside and outside).

The facility submitted an Unusual Incident/Injury Report to the Department on 8/12/19. The report stated that on 8/5/19, child #2 (C2) sustained an injury to right eyebrow. Child #1 (C1) and #2 were playing with plastic bowling pins when C1 threw pin due to frustration of the game.

Based on the facts gathered and interviews conducted, the facility appeared to be in compliance during the incident on 8/5/19. It does not appear the incident was the result of a Title 22 and/or Health & Safety Code violation. Although S1 was in close proximity to C1 and C2 when the incident occurred, S1 was unable to prevent the accident. Staff responded immediately to the child's needs and assisted the child to prevent further harm. Parents were notified immediately.

The content of this report was read and discussed in detail with the licensee. The facility appears in compliance per Title 22 regulations. Type A and B deficiencies will not be cited today 9/11/19.

An exit interview was conducted, a copy of this report and notice of site visit provided to the licensee. Signature was captured on previous subsequent report due to computer inconsistencies.
SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3073
LICENSING EVALUATOR NAME: Helen EstrellaTELEPHONE: (424) 301-3073
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
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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