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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911461
Report Date: 11/04/2019
Date Signed: 11/04/2019 11:05:41 AM

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:ZION LUTHERAN PRESCHOOLFACILITY NUMBER:
360911461
ADMINISTRATOR:M'LESS TRIPPLEFACILITY TYPE:
850
ADDRESS:15342 JERALDO DRIVETELEPHONE:
(760) 243-3074
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY:124CENSUS: 21DATE:
11/04/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:M'Less TrippleTIME COMPLETED:
11:20 AM
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Licensing Program Analyst's (LPAs) Thompson-Miller and Sims met with M'Less Tripple, for a Case Management Incident inspection involving an Incident Report dated 10/30/19. The incident occurred on October 28, 2019.

Description of the incident: Child #1 was on the dome play structure and fell on the sand.
Child #1 was being supervised by Director. Child #1 was sitting on bar #1 close to the ground and holding onto bar #2 (above him) then he let go of bar #2, landing on his foot/ankle. Director immediately attended to his needs as other staff assisted the other children. Director examined Child #1 noticing child would not put pressure on the right leg. An ice pack was put on the right ankle then parent was called. Parent took Child #1 to emergency and it was determined he sustained a broken foot. Child #1 returned to the center on 11/4/19. Center was in ratio during the inciden.

Based on information provided and interviews conducted the incident does not appear to have been the result of any violation of the Title 22 regulation. Exit interview conducted and a copy of report provided to Director, M'Less Tripple on this date.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Linda Thompson-MillerTELEPHONE: (661) 568-8186
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2019
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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