198015514-11-30-2021-33-CC-FVAZ-C8VPUZ-20211118103822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198015514
Report Date: 11/18/2021
Date Signed: 11/30/2021 09:56:07 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	BPUSD - NORTH PARK HIGH SCHOOL		FACILITY NUMBER:	198015514
ADMINISTRATOR:	JERRI SANDELL		FACILITY TYPE:	830
ADDRESS:	4600 N. BOGART AVENUE		TELEPHONE:	(626) 962-3311
CITY:	BALDWIN PARK	STATE: CA	ZIP CODE:	91706
CAPACITY:	40	CENSUS: 6	DATE:	11/18/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Rebecca Jimenez Barlow		TIME COMPLETED:	10:47 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fabiola Vasquez conducted an announced visit to amend the report issued on 11/18/21. A case management inspection was conducted due to an incident that occurred on 11/08/21. LPA met Director, Rebecca Jimenez Barlow, who guided LPA on a tour of the facility at approximately 08:30 AM. During this inspection LPA observed. 02 infants with 02 staff in the Wobblers Room, 0 infants with 02 staff in the Infant Room, 04 toddlers with 03 staff in the toddler room. The incident that occurred on 11/08/21 was reported to the Department on 11/08/21. The facility reported the incident in a timely manner. LPA conducted an interview with Director, and S1. Obtained a copy of the current roster, director will email LPA head injury report, and doctors note on 11/18/21 via email. On 11/08/21 at approximately 10:40 AM, in the toddler playground. Child was running, looked away and tripped over the wheel of a tricycle, falling, and hitting her forehead on the ground next to the rubber surface. Staff who witnessed the fall immediately applied an ice pack on the child’s forehead. Facility contacted child’s legal guardian who contacted the Social Worker. Social Worker advised the child’s authorized representative to take the child to Urgent Care. Child returned to school the following day on 11/09/21. PAGE 1 OF 2

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola Vasquez	TELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: BPUSD - NORTH PARK HIGH SCHOOL	FACILITY NUMBER: 198015514
	VISIT DATE: 11/18/2021

NARRATIVE

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11/18/21 LPA visually observed the space where the incident occurred. A statement was made by S1, where she saw when the child fell and she immediately attended to her. S1 applied an ice pack and contacted the legal guardian. Statements were made by director and S1 the child returned to school the next day 11/09/21 happy and without any restrictions.

Based on all information obtained on this date, no follow-up is necessary regarding the incident. The child was being supervised when the incident occurred. Protocol was followed by the school. LPA observed the yard and advised the director to rearrange the tricycle are. During the visit director rearranged the yard to prevent from reoccurring incidents.

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 Director Rebecca Jimenez Barlow, Appeal rights explained & provided.

There were no deficiencies cited during today’s inspection

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SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola Vasquez	TELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

LIC809 (FAS) - (06/04)

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