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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198006258
Report Date: 05/01/2019
Date Signed: 05/01/2019 12:51:12 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:BELMONT SHORE CHILDREN'S CENTERFACILITY NUMBER:
198006258
ADMINISTRATOR:ANNA MARTINEZFACILITY TYPE:
850
ADDRESS:30 S. TERMINOTELEPHONE:
(562) 439-3369
CITY:LONG BEACHSTATE: CAZIP CODE:
90803
CAPACITY:70CENSUS: 49DATE:
05/01/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Anna MartinezTIME COMPLETED:
01:10 PM
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An unannounced Case Management Inspection was conducted on this day by Licensing Program Analyst (LPA) Raul Navarro to address an Unusual Incident Report that was received in the licensing office on 04/03/2019. LPA met with Director Anna Martinez.

An interview were conducted with Director. Per Director, child collapsed while playing outside and started to have a seizure. Per Director, she observed the entire incident. Parents were called immediately. Parents took child to see a doctor. Per Director, child's parents disclosed to her that child has had a history of having seizures. Per Director, parents did not provide that information when they enrolled the child. Child was cleared by the doctor to come back to the preschool on April 8, 2019. LPA obtained a copy of the Doctor's note during today's inspection.

Based on all information obtained on this date, and an interviews conducted with the Director, no follow-up is necessary regarding the incident. The incident appears to be an unusual accident. It appears to be nothing the facility staff could have done to prevent the incident from occurring. There were no deficiencies observed in regards to today's visit.



Upon receipt of this report, the Director shall post the Notice of Site Visit. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty.

Exit interview was conducted with Director Anna Martinez, copy of report was given. Appeal rights were issued and discussed.

SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2019
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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