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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016464
Report Date: 05/02/2019
Date Signed: 05/02/2019 01:32:31 PM

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:VAN LEEUWEN FAMILY CHILD CAREFACILITY NUMBER:
198016464
ADMINISTRATOR:VAN LEEUWEN, TRINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 522-5192
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:14CENSUS: 13DATE:
05/02/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Trina Van LeeuwenTIME COMPLETED:
01:45 PM
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A Case Management inspection was conducted by Licensing Program Analyst, Timothy Fields for the purpose of following up on an incident reported to CCLD on 4/29/19 involving a child fracturing their leg. Per licensee, two children were involving in the incident. One child was laying on the floor in the accessible living room. The second child was upset and twisted their body in a way that caused them to trip over the child laying on the floor.

The action resulted in the child injuring their fibula. Licensee states she was present in the living room when the incident occurred, but was unable to prevent the accident from happening. The child's parents were contacted. Child was picked up and taken to the Emergency Room. LPA inspected the living room and did not observe any obvious tripping hazards. The child has returned to care and was present on this date.

Exit interview conducted with licensee. Appeal Rights provided and explained. Notice of Site Visit must be posted for (30) days. Failure to do so may result in a $100.00 civil penalty.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Timothy FieldsTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019
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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