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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910831
Report Date: 05/20/2022
Date Signed: 05/20/2022 12:09:02 PM


Document Has Been Signed on 05/20/2022 12:09 PM - 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



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: 53DATE:
05/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:LINDA WALKERTIME COMPLETED:
12:15 PM
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On 05/20/22 Licensing Program Analyst (LPA) Babatunde Ibitoye met with Site Supervisor Linda Walker to conduct an unannounced case management inspection to follow-up on a self- reported unusual incident report on phone by the facility on 05-18-22. Upon arrival, LPA's observed (53) children in classes (60,61,62, 90 , 91) and (2) staff members in each classes.

Description of incident: On 5/12/22, C1 was outside on the playground. C1, is on the autism spectrum and has a 1:1 supervision because C1 requires special instructions and strategies. C1 "likes to run". While on the playground, C1 pushed on the exit bar on the back gate. The back gate opened and C1 stepped outside of the facility and proceeded to run. S1 was right next to C1 and followed C1 outside of the facility. While S1 was running after C1, S1 fell and fractured her hand. C1 continued to run. A "guy" (good Samaritan) not associated to the Child Care Center, assisted S1 and held C1 hand. C1 was safe during the incident and was within full visual supervision the entire time. S1 was injured while performing her duties. There was only one classroom on the playground during the incident. C1 was exited into an empty lot.

Based on the information gathered from observations, record review and interviews conducted with site supervisor additional follow up is needed.

Exit interview was conducted, report was read, and a copy of this report was given to site supervisor along with the appeal rights and notice of site visit.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Babatunde IbitoyeTELEPHONE: 661-568-8179
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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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