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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017621
Report Date: 05/11/2021
Date Signed: 05/12/2021 08:11:53 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:CII/AVALON HEAD STARTFACILITY NUMBER:
198017621
ADMINISTRATOR:THRESA OFFORDFACILITY TYPE:
850
ADDRESS:703 E. 88TH PLACETELEPHONE:
(213) 385-5100
CITY:LOS ANGELESSTATE: CAZIP CODE:
90002
CAPACITY:23CENSUS: 3DATE:
05/11/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Pamela Hartzog, Site SupervisorTIME COMPLETED:
01:30 PM
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Due to COVID-19 and precautionary measures, Licensing Program Analyst (LPA) T. Tran delivered the Incident Report by use of via email to Pamela Hartzog, Site Supervisor on 05/11/2021.

Licensing Program Analyst (LPA) T. Tran conducted a Teleinspection Case Management Incident for the purpose of following up on a self-reported incident occurred on 04/26/2021. Center staff disclosed, on the day of the incident there were 2 staff with 5 children in care. During outdoor play, C1 was running toward the area where children were playing with water and chalks. Staff observed child slipped on the wet chalk and sustained a cut on the left knee. Staff immediately provided medical care. Parent was contacted. Child had returned to school the next without any doctor restrictions. Based on the available information, this incident was not result in the Title 22 Regulations for Lack of Care and Supervision violation. No deficiency was cited.

Exit interview was conducted with the noted person. This report along with a copy of the appeal rights will be sent to Site Supervisor by via email. The confirmation of receipt, which will act as the Site Supervisor's signature.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
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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