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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911538
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:59:18 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:PSD/HESPERIA HEAD STARTFACILITY NUMBER:
360911538
ADMINISTRATOR:HALL, PAULETTEFACILITY TYPE:
850
ADDRESS:9352 E AVENUETELEPHONE:
(760) 948-4411
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:105CENSUS: 53DATE:
11/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Sonia Angulo, Site SupervisorTIME COMPLETED:
03:14 PM
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Licensing Program Analyst (LPA) Thompson-Miller met Sonia Angulo, Site Supervisor, for a Case Management Incident inspection involving an Incident Report dated October 29, 2021. The incident occurred on October 29, 2021. Upon arrival there are 15 children in Child #1 class along with 3 teachers. Total children at the preschool upon arrival are 53 children and 13 staff.

Description of the incident: Child #1 was jumping to catch leaves during outside play time and sustained a small cut from fence.
Child #1 was jumping to catch leaves from the tree. He jumped forward and struck his hand against the top of the chain link fence (photo taken), causing a cut on his right hand. Staff witnessed the incident. Parent was called, Staff attended to the cut. No medical attention was required from the doctor. Staff followed proper emergency procedures. Child #1 returned to the facility the next day.

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, therefore, no deficiencies were cited.

An exit interview was conducted and a copy of this report was read and provided to Sonia Angulo, Site Supervisor on this date.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Linda Thompson-MillerTELEPHONE: (661) 568-8186
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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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