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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017626
Report Date: 11/25/2020
Date Signed: 12/01/2020 03:21:48 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/MAIN STREET HEAD STARTFACILITY NUMBER:
198017626
ADMINISTRATOR:MELISA MORGANFACILITY TYPE:
850
ADDRESS:9505 SOUTH MAIN STREETTELEPHONE:
(213) 385-5100
CITY:LOS ANGELESSTATE: CAZIP CODE:
90003
CAPACITY:90CENSUS: DATE:
11/25/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Site Supervisor, Tamara BeasleyTIME COMPLETED:
02:30 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 Site Supervisor on 11/30/2020.

Licensing Program Analyst (LPA) T. Tran conducted a Case Management Incident by via telephone to follow up on a self-reported incident on 02/06/2020 regarding a staff pulled an enrolled child's arm during nap time. Based on the available information through interviews, parent and facility staff member did not have any concerns to the above incident. Child did not show any signs of discomfort. Therefore, this incident was not result in the Title 22 Regulations for Personal Rights violation. No deficiency was cited.

Exit interview was conducted with the noted person by via telephone during which appeal rights were explained. This report along with a copy of the appeal rights will be sent to licensee by via email with a read receipt or confirmation of receipt of email, 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: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
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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