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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004772
Report Date: 03/03/2020
Date Signed: 03/03/2020 11:13:07 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
FACILITY NAME:COUNTY KIDS' PLACEFACILITY NUMBER:
198004772
ADMINISTRATOR:RODRIQUEZ, ELVIAFACILITY TYPE:
850
ADDRESS:2916 HOPE ST.TELEPHONE:
2137446241
CITY:LOS ANGELESSTATE: CAZIP CODE:
90007
CAPACITY:59CENSUS: 57DATE:
03/03/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Elvia RodriguezTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Mayra Rivera and Raul Navarro conducted a Case Management inspection at the above facility to follow up on the self reported incident that occurred on 02/19/2020. The Monterey Park South West Child Care Regional Office received the incident report on 02/20/2020. LPA’s met with Center Director Elvia Rodriguez who guided the LPA’s on a tour of the facility.

LPAs conducted files review and obtained child's document. Interviews were conducted with staff. Based on the information that were available center staff stated, C1 was twirling around the playground area and last twirl bumped into the post. Child sustained a lump right side upper forehead. No other children were involved. Parent was contacted. Child was taken to the doctor. Child missed one day of school. Per director child is currently attending school. At this time based on the available information it does not appear this incident was the result of a Title 22 violation.

The content of this report was read and discussed in detail at the time with Director Elvia Rodriguez.

An exit interview was conducted and a copy of this report and appeal rights were provided.

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.

SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2020
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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