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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198000639
Report Date: 05/17/2022
Date Signed: 06/01/2022 03:23:25 PM


Document Has Been Signed on 06/01/2022 03:23 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/26/2022 10:33 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

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AMENDED REPORT: LPA deleted confidential information notes page (which included children's names).

Licensing Program Analyst (LPA) Warren Birks conducted an unannounced Case Management Incident inspection. This inspection is regarding incident that took place on May 9, 2022. Licensing Program Analyst met with Assistant Site Supervisor Amber Pimentel who providing information and assistance for the inspection.

During the course of the inspection, LPA conducted interviews with staff #1 and firsthand witness staff #2. Staff #2 indicated that child #1 and child #2 were playing together outdoors and lost their balance. As a result child #1 fell on child #2 (and both children sustained minor injuries). Staff immediately conducted first aid on both children contacted parents. Child #1 was examined by a doctor and returned to the school within 48 hours with no restrictions. LPA also observed both children appearing to perform activities as normal.

LPA observed the playground area where the injury took place to appear safe and free of hazards. LPA also reviewed internal incident reports provided by the facility. There were no corroborated disclosures indicating a Title 22 violation occurred regarding the incident. Based on interviews, observations and review of internal reports there were no violations of Title 22 requirements.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Assistant Site Supervisor Amber Pimentel
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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