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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911276
Report Date: 10/21/2021
Date Signed: 10/21/2021 10:36:23 AM

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:SBCSS ADELANTO STATE PRESCHOOLFACILITY NUMBER:
360911276
ADMINISTRATOR:NANCY ALVARADOFACILITY TYPE:
850
ADDRESS:17927 JONATHAN STREETTELEPHONE:
(760) 246-3396
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:48CENSUS: 23DATE:
10/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:BIANCA ARMIJOTIME COMPLETED:
10:45 AM
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On 10/21/2021 Licensing Program Analyst (LPA) Carol Heath and LPA Babatunde Ibitoye
conducted a Case management incident inspection to follow up on an Unusual Incident
reported to the department on 10/08/2021. LPA’s spoke with the Assistant Teacher Bianca Armijo, A tour of the facility was conducted.
Description of the incident: On 10/08/2021 at 12:05 P.M.an SBCSS Special Education Teacher who is located in the building next door to the classroom stated that her classroom assistant witnessed a State Preschool Staff member throw down a student on the concrete floor a few minutes after arrival. She stated that upon arrival they saw the student visibly upset during drop off at 11:45a.m. and arrived with no shoes or socks and the student was wearing a pink dress.
The purpose of the inspection is to conduct interview with staff that witnesses the
incident. Present during the time of this inspection and providing care is , 3 Teacher with
the 23 children.
The copy of facility roster for the incident day was collected,
Further investigation is needed, An exit interview was conducted, and a copy of this report was read and provided to Assistant teacher Bianca Armijo along with Notice of Site Visit..
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Babatunde IbitoyeTELEPHONE: 661-568-8179
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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