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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017626
Report Date: 10/27/2021
Date Signed: 10/27/2021 02:51:25 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:
2133855100
CITY:LOS ANGELESSTATE: CAZIP CODE:
90003
CAPACITY:90CENSUS: 34DATE:
10/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Tamara Beasley, Site SupervisorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), T. Tran arrived at the above licensed facility to conduct a Case Management Incident inspection that was self-reported on 9/29/2021. The Monterey Park South West Child Care Regional Office received the incident report on 09/30/2021. During the inspection, LPA observed proper care and supervision.

Files review were conducted, and child's document obtained. Based on the interview with staff and other, it revealed that during outside time, C1 was running underneath the play structure where child had hit the cease of left eye. As a result, child sustained a cut over the left eye which required medical attention. Parent was contacted immediately. First aid was provided by staff while waiting for parent to arrive. Per record reviewed, child had returned to school with no restrictions. 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 issued during today's visit. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative Tamara Beasley.

SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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