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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198006261
Report Date: 10/05/2021
Date Signed: 10/05/2021 10:46:15 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:VAN WIG HEAD START/STATE PRESCHOOLFACILITY NUMBER:
198006261
ADMINISTRATOR:JOANNE MENDEZFACILITY TYPE:
850
ADDRESS:1151 VAN WIG AVE.TELEPHONE:
(626) 931-8000
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY:72CENSUS: 17DATE:
10/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Rosa Ducoing, Child Development Program DirectorTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Lissete Gonzalez and Lilli Babcock conducted an unannounced Case Management inspection due to an incident which occurred on 09/02/21. LPAs met with Child Development Program Director, Rosa Ducoing. LPAs were guided on a tour of the facility at approximately 9:20AM with Child Development Program Director, Rosa Ducoing.

The incident that occurred on 09/02/21 was reported to the Department on 09/03/21 via telephone. The facility reported the incident in a timely manner.

LPAs conducted interviews and obtained documentation during this visit including the child care facility roster and ouch reports for children currently enrolled. LPAs also visually observed the outdoor playground where the incident occurred.

On 09/02/21, during outdoor play time a child sustained an injury to their left elbow after falling from a slide as the child had attempted to climb up the slide. The injury did result in required medical attention. LPAs observed the areas around and under the slide are cushioned with material that absorbs falls. LPAs also observed the play equipment slide to be age appropriate. Staff interviews corroborated the statement that staff were in close proximity and tended to the child immediately after the accident. Based on all information obtained on this date and interviews conducted with staff, no follow-up is necessary regarding the incident. The incident appears to be an unusual incident.

Exit interview was conducted with Child Development Program Director, Rosa Ducoing. 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: Christina GabelmanTELEPHONE: (323) 981-3383
LICENSING EVALUATOR NAME: Lissete GonzalezTELEPHONE: (323) 981-3383
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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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