<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910831
Report Date: 11/15/2019
Date Signed: 03/06/2020 01:06:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:PSD/APPLE VALLEY HEAD STARTFACILITY NUMBER:
360910831
ADMINISTRATOR:DOLORES EDWARDSFACILITY TYPE:
850
ADDRESS:13589 NAVAJO ROADTELEPHONE:
(760) 247-6955
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:117CENSUS: 0DATE:
11/15/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Dee Edwards Site SupervisorTIME COMPLETED:
12:49 PM
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 03-06-2020 at PSD Apple Valley Head Start , Licensing Program Analyst (LPA) Steven Montoya conducted a subsequent case management inspection for the purpose of amending case management report dated 11-15-2019.

The incident states of 11-07-2019, during free play, Child # 1 was pushing a toy wheelchair resulting in child #1 losing his balance and hitting the right side of his eye and eyebrow. A small amount of blood and two red marks were noticed above child #1's right eye. Staff provided First aid to child # 1. Parents were contacted immediately.

LPA conducted interviews Site Supervisor and staff. At this time, further follow up is needed.

An exit Interview was conducted and a copy of the report was provided to site supervisor.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (661) 789-8932
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: PSD/APPLE VALLEY HEAD START
FACILITY NUMBER: 360910831
VISIT DATE: 11/15/2019
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
26
27
28
29
30
31
32
On 11-07-2019, Foster parent took child to hospital for stitches and was ordered to return in 10 days to remove stitches.

SS reports licensing was contacted on 11-14-2019. On 11-07-2019, Foster parent was contacted at 2:27 pm and again at 2:31 pm on both the cell and home phone. On 11-08-2019, SS contacted parent at 9:40 am and again at 2:42 pm on both home and cell phone numbers. On 11-12-2019, SS spoke to parents regarding the phone calls.

At the time of the investigation, the child 1 was not present and staff 1 (teacher) was of on friday flex leave.

Exit interview conducted and a copy of the report was provided to the facility staff.
Appeal rights was also printed and provided.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (661) 789-8932
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME: PSD/APPLE VALLEY HEAD START
FACILITY NUMBER: 360910831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
12/17/2019
Section Cited

1
2
3
4
5
6
7
Based on the investigation consistent to interviews with staff and review of supportive evidence. The facility is being cited for Type B violation of: 101212 (D) (1) (b)- Facility failed to comply with Health and Safety Reporting Requirements. Incident occured on 11-07-2019 but was reported on 11-14-2019.

1
2
3
4
5
6
7

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (661) 789-8932
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3