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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198002482
Report Date: 11/23/2020
Date Signed: 11/24/2020 03:52:45 PM

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
FACILITY NAME:MAOF HEAD START ZOE AVENUE CENTERFACILITY NUMBER:
198002482
ADMINISTRATOR:CYNTHIA RODRIGUEZFACILITY TYPE:
850
ADDRESS:2650 ZOE AVE.TELEPHONE:
3235845828
CITY:HUNTINGTON PARKSTATE: CAZIP CODE:
90255
CAPACITY:85CENSUS: DATE:
11/23/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria Cecilia, Area SupervisorTIME COMPLETED:
04:00 PM
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Due to COVID-19 and precautionary measures, Licensing Program Analyst (LPA) T. Tran delivered the Incident Report by use of via email to Maria Cecilia, Area Supervisor on 11/23/2020.

Licensing Program Analyst (LPA) T. Tran conducted a Case Management Incident by via telephone to follow up on a self-reported incident on 04/25/2019 regarding an enrolled child missed the step while going up the play structure then fell and hit the left eyebrow on the playground structure. Medical attention required. Based on the available information, on the day of the incident there were two staff supervised about 15 children. Per staff, none of the children in care involved in this incident. Play structure was assessed for safety purposes. Therefore, this incident was not result in the Title 22 Regulations for Lack of Care and Supervision violation. No deficiency was cited.

Exit interview was conducted with the noted person by via telephone during which appeal rights were explained. This report along with a copy of the appeal rights will be sent to licensee by via email with a read receipt or confirmation of receipt of email, which will act as the Area Supervisor's signature.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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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