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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911461
Report Date: 03/04/2022
Date Signed: 03/04/2022 11:55:00 AM


Document Has Been Signed on 03/04/2022 11:55 AM - 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: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: 16DATE:
03/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:M'Less TrippleTIME COMPLETED:
12:10 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 February 24, 2022. The incident occurred on February 22, 2022.

Description of the incident: Child #1 hit Child #2
Children were instructed to clean up. Child #2 started cleaning up, picked up a toy in which Child #1 ran over and began to try and take the toy from Child #2. The children were sitting on the floor pulling the toy. Child #1 let go of the toy and Child #2 fell backward, no marks or bruising. Neither child cried. Parents were informed and Staff #1 observed the entire incident. Staff #1 talked to both children. Child #1 no longer attends as of 3/3/22.

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 was read and provided to Director M'Less Tripple.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Linda Thompson-MillerTELEPHONE: (661) 568-8186
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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