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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198007699
Report Date: 01/22/2020
Date Signed: 01/22/2020 10:59:08 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:COLUMBIA PLAZA EARLY CHILDHOOD EDUCATION CENTERFACILITY NUMBER:
198007699
ADMINISTRATOR:QUETA MORALESFACILITY TYPE:
830
ADDRESS:12830 COLUMBIA WAY (CLARK)TELEPHONE:
(562) 803-6229
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY:84CENSUS: 53DATE:
01/22/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Site SupervisorTIME COMPLETED:
11:10 AM
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Licensing Program Analysts (LPAs) Tiffanie Tran and Jose Guzman conducted a Case Management inspection at the above facility to follow up on the self-reported incident that occurred on 08/08/2019. The Monterey Park South West Child Care Regional Office received the incident report on 08/12/2019.

LPAs conducted files review and obtained child's and other document. Based on the information that were available during morning outdoor play, S1 observed C1 was playing with the balancing board then fell and hit her forehead on the fence. Child sustained a bump on the forehead. No other children were involved. Parent was contacted. Child was taken to the doctor for checkup and returned to school the next day with no restriction. To prevent future incident from reoccurrence, staff had removed the balance board. At this time based on the available information it does not appear this incident was the result of a Title 22 violation for lack of care and supervision.

The content of this report was read and discussed in detail at the time of with the noted contact person.

An exit interview was conducted; the notice of site visit must be posted for 30 days upon receipt.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020
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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