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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017204
Report Date: 09/28/2021
Date Signed: 09/28/2021 01:36:22 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:VOLUNTEERS OF AMERICA, PARAMOUNT HEAD STARTFACILITY NUMBER:
198017204
ADMINISTRATOR:BRENDA LOPEZFACILITY TYPE:
850
ADDRESS:6719 SOMERSET BOULEVARDTELEPHONE:
3109330733
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY:83CENSUS: 27DATE:
09/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Brenda Lopez, Site SupervisorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) T. Tran and Licensing Program Manager T. Cochran arrived at above licensed facility to conduct a Case Management inspection that was self-reported on 08/26/2021 regards a child in care fell and sustained a clavicle fracture of the left arm. The Monterey Park South West Child Care Regional Office received the incident report on 08/26/2021.

LPA toured the facility indoor and outdoor. File review was conducted, and document were obtained. On the day of the incident, there were two staff supervised 09 children in care. Based on the information that were gathered during today's interviews, no other children were involved. Parent was contacted.

At this time based on the available information it does not appear this incident was the result of a Title 22 violation for lack of care and supervision. No deficiency was cited.

The content of this report was read and discussed in detail with the noted person.

An exit interview was conducted; the notice of site visit must be posted for 30 days upon receipt.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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