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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750009
Report Date: 09/19/2019
Date Signed: 09/19/2019 02:33:09 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:CCRC EHS LPCFACILITY NUMBER:
197750009
ADMINISTRATOR:ZAMORANO-PEDREGON, BEATRIZFACILITY TYPE:
830
ADDRESS:2320 EAST AVE RTELEPHONE:
(818) 717-1000
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:52CENSUS: 28DATE:
09/19/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Theresa MilesTIME COMPLETED:
02:47 PM
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Licensing Program Analyst's (LPAs) Smith and Thompson-Miller met with Theresa Miles Center Director , for a Case Management Incident inspection involving an Incident Report dated 9/17/19. The incident occurred on 9/16/19. There are 28 children on site during the inspection. Classroom one currently has present eight, children, five months to fourteen months. Classroom two currently has present six children, ages fourteen months to two years old. Classroom three currently has present seven children, eighteen months to two years. Classroom four currently has present seven, two years to three years old.

Description of the incident: Two Day Care children were climbing on an activity structure in the classroom. Child #1 was climbing up the structure while Child #2 started climbing up and bouncing on the climbing structure. Child #1 fell off the climbing structure and hurt her left arm. Incident occurred in classroom #3.

The Director provided a copy of the Roster. Interviews were conducted with Staff. Photos were taken of classroom and climbing structure.

Based on information provided and interviews conducted, further investigation is needed. An exit interview was conducted and a copy of this report was read and given to Theresa Miles.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Suzanne SmithTELEPHONE: (661) 305-3012
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019
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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