198018225-12-8-2022-33-CC-MJAA-CLWQJJ-20221208111250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198018225
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:12:59 AM

Document Has Been Signed on 12/08/2022 11:12 AM - It Cannot Be Edited

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	PARA LOS NINOS HEAD START - HOLLYWOOD		FACILITY NUMBER:	198018225
ADMINISTRATOR:	ANGELA CAPONE		FACILITY TYPE:	850
ADDRESS:	5000 HOLLYWOOD BLVD		TELEPHONE:	(213) 250-4800
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90027
CAPACITY:	60	CENSUS: 23	DATE:	12/08/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Vanessa Quezada, Area Supervisor		TIME COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On December 8, 2022 at 8:05AM, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced case management inspection at the above facility. A COVID-19 risk assessment was conducted prior to entering the facility. The purpose of this inspection is to follow up on an unusual incident report that occurred on 11/21/2022 and was filed with our department on 11/22/2022. The report was reported on time. LPA met with Family Service Specialist, Elizabeth Martinez who guided LPA on a tour of the facility. Area Supervisor, Vanessa Quezada arrived shortly after. LPA observed 23 children in care with 6 staff. Brief Summary of Incident: On 11/21/2022 at approximately 9AM, Child #1 (C1) was trying to around Child #2 (C2) on the play structure when C2 pushed C1 off causing C1 to fall. C1 fell face first hitting his head and nose sustaining minor scratches. The play structure has rubber material beneath. The facility gave C1 and ice pack and called C1's mother. C1's mother picked him up from the facility at C1 was taken to urgent care. C1 returned to the facility the next day with no injuries, just the minor scratches. During this investigation, LPA interviewed, staff #1 (S1), staff #2 (S2), staff #3 (S3) and child #1 (C1). Per S1, she stated that she observed the incident with C2 pushing C1. Per S1 she assisted C1 while S2 supported with C2 and supervised the remainder of the children. Per C1 both S1 and S2 were present during the time of the incident. Per S1 and S2 and incident report was provided to C1's mother and C2's mother was notified via telephone.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica Ayala	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PARA LOS NINOS HEAD START - HOLLYWOOD	FACILITY NUMBER: 198018225
	VISIT DATE: 12/08/2022

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There are no deficiencies being cited as this was an incident that occurred fast and was unable to be prevented. Per S1 she witnessed the incident occur and took the proper measures to ensure C1 received the proper first aid care.

LPA observed the play structure to be age appropriate for preschool age children, LPA observed the cushioned material (rubber padding) to be in good repair. This incident was an accident.

An exit interview was conducted and a copy of this report was provided to area supervisor along with Notice of Site Visit and appeal rights.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica Ayala	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC809 (FAS) - (06/04)

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