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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750105
Report Date: 03/09/2022
Date Signed: 03/09/2022 02:11:40 PM


Document Has Been Signed on 03/09/2022 02:11 PM - 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:GARDEN PATCH PLAY SCHOOL, THEFACILITY NUMBER:
197750105
ADMINISTRATOR:CHRISTIE COPLEYFACILITY TYPE:
850
ADDRESS:24436 VALLEY STTELEPHONE:
(661) 888-1198
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY:45CENSUS: 43DATE:
03/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Christie Copley, DirectorTIME COMPLETED:
02:15 PM
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On March 9, 2022, Licensing Program Analyst (LPAs) Monique Ayala conducted a case management inspection to follow up on an Unusual Incident reported to the department by telephone on 03/01/2022; this incident was reported timely. LPA was greeted by assistant director Katherine who guided LPA on a tour of the facility. Director arrived shortly after and completed tour with LPA. Upon arrival, there were 43 children and 12 staff present today.

Description of incident: On 02/28/2022 Child 1 was playing with Child 2. C1 turned to run and play and tripped over his feet. C1 fell to the ground and hit his head. Staff 1 applied pressure to the forehead which was bleeding. Director called C1's mother. C1 was taken to the hospital where C1 received 4 stiches. (Children and Staff names are located on LIC811, confidential names).

During this inspection, LPA interviewed staff, director, children, obtained images of where the incident occurred and obtained a copy of the facility roster.

The information obtained during the interviews revealed that the S1 was in close proximity to C1 during the time of the incident. S1 was approximately 10 feet away from C1. C1 was playing with C2 sword fighting (sword is a pool noodle) and turned to run into the grass area. C1 tripped over his feet and hit his forehead on the tree stump that resulted in a head injury that needed 4 stiches. S1 was in close proximity and was not able to prevent the incident from happening as the incident occurred fast. There was no disclosure during interviews that an object on the ground may have caused the injury. Per staff the ground was clear.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 369-2168
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: (661) 202-3365
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GARDEN PATCH PLAY SCHOOL, THE
FACILITY NUMBER: 197750105
VISIT DATE: 03/09/2022
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No violation of Title 22 Regulations occurred due to the incident being an accident. No deficiencies cited during this inspection.

An exit interview was conducted and a copy of this report was provided to director along with Notice of site visit.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 369-2168
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: (661) 202-3365
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
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