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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004841
Report Date: 10/05/2022
Date Signed: 10/05/2022 03:49:56 PM


Document Has Been Signed on 10/05/2022 03:49 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:LONG BEACH CITY COLLEGE CDCFACILITY NUMBER:
198004841
ADMINISTRATOR:AMY BIGELOWFACILITY TYPE:
850
ADDRESS:4630 CLARK AVETELEPHONE:
(562) 938-4253
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:115CENSUS: 52DATE:
10/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:44 PM
MET WITH:Amy BigelowTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Warren Birks conducted a Case Management Incident inspection. This inspection is regarding an incident that took place on September 27, 2022. LPA met with Director Amy Bigelow who provided information and assistance during the inspection.

Staff #1 guided LPA to the outdoor play area to observe where child #1 was injured. LPA observed the area to appear to be in normal condition (clean, orderly and free of hazards). LPA also observed the playground equipment in working condition. Staff #1 indicated they were approximately ten feet away observing the area (including child #1 and child #2) when the injury took place. Staff #1 indicated child #2 pushed child #1 off of a 4 foot playground equipment platform, and caused child #1 to fall to the ground. The fall caused child #1 to sustain an injury near the shoulder area. Staff #1 and Staff #2 indicated that staff #1 was in the vicinity when the injury took place.

Post injury Staff #1 brought child #1 in the classroom and where Staff #2 conducted first aid. Staff then contacted parents for pick up. The child was taken to the hospital for medical treatment and returned to school a week later with limited restrictions. Staff followed the required protocol in terms of first aid and "reporting requirements" as the 9/27/2022 incident was reported to Child Care Licensing within 24 hours or the next business day. The Information provided matches the incident report. Based on interviews and observations 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 Director Amy Bigelow.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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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