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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013658
Report Date: 10/14/2021
Date Signed: 10/14/2021 12:04:19 PM

Document Has Been Signed on 10/14/2021 12:04 PM - It Cannot Be Edited

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:EL MONTE CITY SCHOOL DIST.-SHIRPSER SCHOOL (H.S.)FACILITY NUMBER:
198013658
ADMINISTRATOR:LISA DUNBARFACILITY TYPE:
850
ADDRESS:4020 N. GIBSON ROADTELEPHONE:
(626) 453-3700
CITY:EL MONTESTATE: CAZIP CODE:
91731
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 14DATE:
10/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teacher, Lidia AvalosTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Fabiola Vasquez conducted an unannounced Case Management inspection due to an incident which occurred on 09/30/21. LPA met Teacher , Lidia Avalos, who guided LPA on a tour of the facility at approximately 09:00 AM. During this inspection LPA observed 14 children with 02 staff.

The incident that occurred on 09/30/21 was reported to the Department on 10/01/21 via mail. The facility reported the incident in a timely manner. LPA conducted interviews with S1, S2 and Director and obtained documentation during this visit including the child care facility roster, doctor's report and ouch report. LPA also visually observed the outdoor space in the playground where the incident occurred.

On 09/30/21 a child was running in the playground and tripped on a balance block landing on his left arm.
The injury required medical attention leading to the child wearing a cast until doctor's clearance date unknown. LPA observed the balance block that the child tripped on and the space area where the child fell. LPA observed that there is grass turf around the perimeter that can absorb a child's fall. LPA observed the balance block to be age appropriate and the balance block was in the area where children play.

Interviews with S1, S2 and director disclosed statement that staff were in close proximity and tended to the child immediately after the accident. Other statements by staff disclosed were that the balance blocks were removed to prevent future accidents from occurring. LPA observed the balance blocks to be stored away in a classroom that is not being used at this time. Based on all information obtained on this date and interviews conducted with staff, no follow-up is necessary regarding the incident. The incident appears to be an unusual incident.
No citations are being issued.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Supervisor, Denise Maria, Appeal rights explained & provided.
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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