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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013176
Report Date: 09/18/2019
Date Signed: 09/18/2019 04:30:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:MARY ALICE O' CONNOR CCLCFACILITY NUMBER:
198013176
ADMINISTRATOR:AMANDA EDWARDSFACILITY TYPE:
850
ADDRESS:401 N. BUENA VISTA STREETTELEPHONE:
8188461063
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY:68CENSUS: 20DATE:
09/18/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Amanda Edwards, DirectorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA), Sophia Lord-Richard, conducted a Case Management Incident Report visit to follow up on self reported incident that occurred at Mary Alice O'Connor CCLC on 5/16/2019.

The El Segundo Child care Office received the incident report on May 17, 2019, by Program Specialist, Maria Martinez. Program Specialist reported that on May 16, 2019, a child reported to the teacher that a friend in her class had a Wiggly Eye suck in her nose. The teacher assessed the child and notified the Program Specialist. They assessed that child and contacted child's parent immediately. The child was picked up by their parent and taken to the doctor where the object was removed from the child's nostril. The child was release to return back to school the next day.

Based upon the information obtained through interviews and visual observation, the child's injury does not appear to be the result of a Lack of Care or Supervision or Personal Rights violation.

LPA reviewed child’s file, staff files and obtained documents. Based on today’s visit, and interviews conducted, the Incident does not appear to be the results of a regulatory violation. The investigation into the above unusual incident/injury does not require any further investigation. An exit interview was conducted, copy of this report, and notice of site visit issued.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Sophia Lord-RichardTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
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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