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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911461
Report Date: 04/16/2021
Date Signed: 04/16/2021 01:44:19 PM

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: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: 18DATE:
04/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:M'Less TrippleTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Thompson-Miller met with Director, M'Less Tripple, for a Case Management Incident inspection involving an Incident Report dated April 9, 2021. The incident occurred on April 7, 2021 (telephoned on 4/8/21). The inspection conducted as a Tele-Visit due to COVID-19.

Description of the incident: Child #1 was hit by Child #2 on the right eye
Children were in the play ground area. Child #2 (playing with a plastic hammer and toy) and Director (shadowing Child #2) were at the patio area. Child #1 was putting up a bike (approximately 4 feet from Director and bike area). Another child approached Director crying in need of attention. Child #1 screamed. Director observed Child #1 holding his right eye and crying. There were a total of 4 staff present, each attending to the children in their area while outside and did not witness the incident. An ice pack was put on the right eye and parent was called. Child #1 returned to the center on 4/8/21, no stitches and no bruising. Child #2 no longer attends. Center was within ratio during the time of the incident.
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 this report will be emailed to Director M'Less Tripple (due to COVID-19). The read receipt is in lieu of a signature.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Linda Thompson-MillerTELEPHONE: (661) 568-8186
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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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