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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011088
Report Date: 02/03/2020
Date Signed: 02/03/2020 02:52:31 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:PACE HEAD START/EVEN START CENTERFACILITY NUMBER:
198011088
ADMINISTRATOR:MARTHA HERNANDEZFACILITY TYPE:
850
ADDRESS:2300 W. JAMES M. WOOD BLVD.TELEPHONE:
(213) 738-7295
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY:30CENSUS: 21DATE:
02/03/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Regional Site DirectorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) T. Tran conducted a Case Management Inspection at the above facility to follow up on the self-reported incident that occurred on 10/14/2019. The Monterey Park South West Child Care Regional Office received the written incident report on 10/16/2019.

LPA conducted files review and obtained child's document. Based on the information that were available, there were two teachers present with no more than 15 children on the day of the incident. During afternoon outdoor play, staff observed C1 sliding down the slide and landed on his right arm. Child was crying however, showed no signs of pain or discomfort. No other children were involved. Parent was not contacted but was informed of the incident upon pick up time. The next morning, Parent of C1 contacted the school and informed the staff child had admitted to ER the night of the incident and had a half cast due to dislocated right elbow. 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: 02/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2020
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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