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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494325
Report Date: 02/20/2020
Date Signed: 02/20/2020 04:27:52 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:CRYSTAL STAIRS HEAD START - CHAPEL OF PEACEFACILITY NUMBER:
197494325
ADMINISTRATOR:CARDENAS, LAURAFACILITY TYPE:
850
ADDRESS:1009 NORTH MARKET STREETTELEPHONE:
(323) 421-1100
CITY:INGLEWOODSTATE: CAZIP CODE:
90302
CAPACITY:55CENSUS: DATE:
02/20/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Shaniece Smith (site Supervisor)TIME COMPLETED:
04:45 PM
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On 2/20/2020 at 3:00 pm, Licensing Program Analyst (LPA) Lourdes Castellanos conducted an unannounced case management visit for the purpose to follow up on an Unusual Incident/Injury Report (UIR) that occurred at the facility on 12/12/19. Upon arrival, LPA met with the Director Shaniece Smith Site Supervisor and informed her the nature of the inspection. LPA observed 10 children in class D at the facility being supervised by 2 staff. LPA confirmed that all adults on the premises have obtained a criminal record clearance and are associated to the facility.

On 12/12/2020 C1 was sitting on a bench in the playground.C1 turned around, lost her balance. C1 sustained an injury to her left arm ( broken arm).
During this inspection, LPA conducted interviews with facility staff and inspect the playground area.

LPA’s toured the facility including the playground where the injury happened. During the visit at 3:15pm, LPA's inspected the structure (Outdoor equipment inspected for safety, cushioning material, good repair and age appropriateness). LPA Castellanos took photos. There are no visible signs that there are any defects to the benches on the play area. LPA observed the structure (bench) itself is appropriate for children ages 2 to 5 years old. Underneath the structure (bench) area is on resilient rubber cushioning. Facility was in ratio there were 9 children present and 2 staff when the incident/injury took place in the outdoor play yard.

Based on the facts gathered and interviews conducted, the facility appeared to be in compliance during the incident on 12/12/19. It does not appear the incident was the result of a Title 22 and/or Health & Safety Code violation. Although Staff #1 was in close proximity to C1 when the incident occurred, S1 was unable to prevent the accident. S1, S2 respond immediately. First aid was immediately administered. facility submitted a timely incident report. C1 return to facility on 1/7/2020 with restriction . A copy of the Health Services Action Plan for C1 was provided to LPA.


An exit interview was conducted, a copy of this report and notice of site visit provided to the site Supervisor Shaniece Smith.
SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Lourdes CastellanosTELEPHONE: (424) 301-3066
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020
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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