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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017622
Report Date: 05/08/2019
Date Signed: 05/13/2019 02:30:43 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:CII/GREEN MEADOWS HEAD STARTFACILITY NUMBER:
198017622
ADMINISTRATOR:MICHELLE SAKATIANFACILITY TYPE:
850
ADDRESS:8835 S. AVALON BLVD.TELEPHONE:
(213) 385-5100
CITY:LOS ANGELESSTATE: CAZIP CODE:
90003
CAPACITY:38CENSUS: 30DATE:
05/08/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Pamela Hartzog/Site SupervisorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Silva Garibyan, met with the site supervisor upon arrival to the facility. LPA conducted the visit for the purpose of following up on an Unusual Incident report received in the Regional office on 02/26/19 (incident occurred on 02/25/2019). According to this report: " On Monday, February 25, 2019 at 9:48 am, Child #1 was playing outside on the pole of the play structure. He jumped down and fell on his right wrist putting all his/her weight on his/her wrist. Staff #1 immediately tended to Child #1 and Administered first aid, applying ice on the wrist. Staff #1 notified Staff #2 and Staff #2 called Child #1's mother at 9:53 am. Parent picked up the child at 9:59 and was provided an Ouch Report. Child #1 sustained closed fracture of distal end of radius. Cast was applied , as well as bandage near wrist.

During the visit LPA toured the area where child fell. The structure appeared to be well anchored and age appropriate. There is also soft padding around the entire area. In addition, LPA interviewed Staff #1 and Staff #3, who stated that they observed child jump off. Currently Child #1 is not attending the facility. All reporting requirement were met.

LPA has determined that the incident was an accident. No deficiencies are being cited in accordance to Title 22 California Coder of Regulations.

Exit interview conducted with Director. Appeal rights provided and explained. Notice of Site Visit provided and must be posted for 30 days.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
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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