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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013176
Report Date: 10/18/2019
Date Signed: 10/18/2019 05:06:52 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:
(818) 846-1063
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY:68CENSUS: 64DATE:
10/18/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Maria Martinez - Program SpecialistTIME COMPLETED:
03:50 PM
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On 10/1/82019 at 01:50 pm, Licensing Program Analyst (LPA) Denise Miranda arrived at Mary Alice O’Connor, located at 401 N. Buena Vista Street, Burbank, CA 91506 for the purpose of following up on the unusual incident that occurred at the facility on 08/13/2019. The El Segundo received the Unusual Incident/Injury Report (UIR) via fax on 8/14/2019. LPA met with Maria Martinez, Program Specialist, and discussed the purpose of the visit.
During this visit, facility has 64 children napping and 13 teachers are providing care and supervision.

According to the report that the Department received, on 08/13/2019 at 10:55am, child#1 tripped over her own feet, causing her to fell and hit her mouth on a chair. The child returned to the facility on 8/15/2019.

During this inspection, LPA conducted an interview with facility staff involved in the incident. LPA also reviewed teachers and child’s records.

Based on the information gathered throughout the course of the investigation, it does not appear that the incident was a result of a Title 22 violation. Facility staff witnessed the incident, acted immediately and first aid was administered. Child's parents were also immediately notified of the incident and Facility was in compliance with teachers-Child ratio.

An exit interview was conducted and a copy of this report along with the Notice of Site Visit were provided to Maria Martinez, Program Specialist.
SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2019
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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