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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198009693
Report Date: 01/12/2022
Date Signed: 01/12/2022 11:07:26 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:JOHNSTON ELEMENTARY SCHOOLFACILITY NUMBER:
198009693
ADMINISTRATOR:SOFIA ESPINOZAFACILITY TYPE:
850
ADDRESS:13421 S. FAIRFORD AVE.TELEPHONE:
(562) 210-2508
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:38CENSUS: 0DATE:
01/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Leticia Ponce, TeacherTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) T. Tran arrived at Johnston Elementary School Head Start to conduct an unannounced Case Management inspection that was self-reported on 1/07/2022 regarding a child in care fell off the chair and sustained a laceration to the forehead. The Monterey Park South West Child Care Regional Office received the incident report on 1/08/2021. Upon arrival, LPA did not any children in care. Per staff, children are currently doing virtual learning due to the recent Covid-19 exposure.

LPA completed staff and child file reviewed. LPA obtained personnel report and child's record. Based on the information that were gathered through interviews with staff and other. On the day of the incident, there were two staff supervised 10 children. Staff immediately dialed 911 and parent was contacted. According to the available information, it does not appear this incident was the result of the Title 22 violation for lack of care and supervision.

No deficiency was cited at this time. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Leticia Ponce.

SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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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