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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750040
Report Date: 04/25/2022
Date Signed: 05/27/2022 10:26:06 AM


Document Has Been Signed on 05/27/2022 10:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:PALMDALE SCHOOL DISTRICT - DO HEAD STARTFACILITY NUMBER:
197750040
ADMINISTRATOR:DR. MELANIE CULVERFACILITY TYPE:
850
ADDRESS:975 EAST AVENUE P-8TELEPHONE:
(661) 273-4710
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:15CENSUS: 15DATE:
04/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:MELANIE CULVERTIME COMPLETED:
02:30 PM
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On 04/25/2022 Licensing Program Analyst (LPA) Carol Heath conducted a Case management incident inspection to follow up on an Unusual Incident reported to the department by email on 04/21/2022. LPA Justin Dorsey received LIC 624 (UIR).

Description of the incident: On 02/20/2021 at approximately 10:15 AM. A teacher reported child 1 (4 years old) was crying and cradling her left arm. LVN-Agraz went to the classroom to check on the child and child #1 was grimacing due to the discomfort. RN-Ermilio was called to check the child and determined that child #1 should be seen at the hospital. Child #1’s mother was called around 10:30 am and the child’s father picked up the child around 10:55 am. The child was seen at Palmdale Regional Medical Center.

On 4/22/2022, LPA spoke with Palmdale School District: Do Head Start (197750040) Director Melanie Culver. This interview inspection was conducted via Tele-Visit. There were 14 children in care today. During 4/22/2022, the Tele-Visit interview inspection, LPA requested a census of the children present, interviews with the director, and requested pertinent documentation related to the incident (Facility Roster, Sign in/out, and Child’s file).

On 4/25/2022, during the facility visit, LPA interviewed 2 teachers, 5 children, and a Nurse.

Based on the information provided, further investigation is needed at this time.

Exit interview was conducted and the report was reviewed with the facility representative Melanie Culver.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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