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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018039
Report Date: 01/14/2020
Date Signed: 01/14/2020 01:01:40 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:MAOF HEAD START- BETA VISTAFACILITY NUMBER:
198018039
ADMINISTRATOR:ESTHER Q-BLAKEFACILITY TYPE:
850
ADDRESS:1403 E. 21ST ST.TELEPHONE:
(213) 741-6325
CITY:LOS ANGELESSTATE: CAZIP CODE:
90011
CAPACITY:40CENSUS: 33DATE:
01/14/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Head Teacher TIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Tiffanie Tran conducted a Case Management inspection at the above facility to follow up on the self-reported incident that occurred on 10/02/2019. The Monterey Park South West Child Care Regional Office received the incident report on 10/02/2019.

LPA completed child and staff reviewed. LPA obtained personnel and child’s documentation.
On the day of the incident there were two teachers with 16 children. LPA interviewed staffs and others. Based on the available information that were gathered through interviews and record reviewed, during nap time, C1 was getting up and tripped in his cot. Child fell on his right arm. There were no other children involved. Mother was contacted immediately. Child sustained a fracture on right elbow and had a cast for a month. During this period, individualize plan was in place to accommodate child needs.
At this time, no deficiencies were observed or cited in relation to this incident. Based on the available information it does not appear this incident was the result of a Title 22 violation.

The content of this report was read and discussed in detail at the time of with the noted contact 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: 01/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2020
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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