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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198014185
Report Date: 10/01/2021
Date Signed: 10/01/2021 09:58:12 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:KID WORKS CHILDREN'S CENTERFACILITY NUMBER:
198014185
ADMINISTRATOR:RANASINGHE, D.FACILITY TYPE:
850
ADDRESS:3621 E. BROADWAYTELEPHONE:
(562) 438-4904
CITY:LONG BEACHSTATE: CAZIP CODE:
90803
CAPACITY:50CENSUS: 20DATE:
10/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Amy ChiuTIME COMPLETED:
10:17 AM
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An unannounced Case Management Inspection was conducted on this day by Licensing Program Analyst (LPA) Raul Navarro to address an Unusual Incident Report that was received in the licensing office on 08/11/21. LPA arrived at the facility at 8:45am and met with Director Amy Chiu who guided LPA on a tour of facility.

On 08/10/21, at approximately 3:15pm, Child #1 was winding the school swing around. Child got dizzy and flung his body. Child lost his footing and fell of the ledge and hit his head on the ground. Child scraped his elbow and had a small circular injury on the side of his head. Staff observed a tiny rock embedded inside the injury. Per report, incident occurred in front of two staff. Staff #1 observed the incident and tended to child. Staff #2 was out in the playground and also observed the incident. Director was immediately notified. Staff cleaned the injuries and applied ice. Staff #1 called child's parent to notify of the incident. Parent picked up child and took child to the doctor where they received stiches.

LPA interviewed Staff #2 during inspection. Per Staff #2, Child was spinning around while holding the swing. Child became dizzy and was stumbling. Child lost their balance and fell over the ledge causing an injury to their elbow and side of their head. Staff #1 was not available for interview. Child returned to school the next day after the incident.

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 accident. It appears to be nothing the facility staff could have done to prevent the incident from occurring. There were no deficiencies observed in regards to today's visit.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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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