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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911568
Report Date: 12/04/2019
Date Signed: 12/04/2019 01:00:36 PM

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:PSD-TWENTY NINE PALMS HEAD STARTFACILITY NUMBER:
360911568
ADMINISTRATOR:WILSON, DEBORAHFACILITY TYPE:
850
ADDRESS:71409 29 PALMS HIGHWAYTELEPHONE:
(760) 367-5150
CITY:TWENTYNINE PALMSSTATE: CAZIP CODE:
92277
CAPACITY:45CENSUS: 23DATE:
12/04/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Deborah WilsonTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Aaron Mabika met, Deborah Wilson, Site Supervisor for a Case Management Incident inspection involving an Incident Report dated 11/14/2019. The incident occurred on 11/13/2019.

Description of the incident: On 11/13/2019 at 8am as Child # 1 got off the bus, Citisha Dowell, teacher aide and Kimberly Stephenson, generalist noticed Child # 1 had a mark on her nose and she was holding her face. When Child # 1 looked up Kimberly noticed other marks on her face. Kimberly Stephenson asked her what happened, and Child # 1 said, “Mommy did.” Citisha Dowell saw it and asked her what happened, and Child # 1 said, “Mommy hit me on the face.” Child # 1 was brought to the site supervisor, the supervisor asked her what happened, and Child # 1 said, “Mommy hit me.”

Facility followed the reporting protocol. The child is said to be still enrolled at the center by attendance withdrawn pending the outcome of the case with CPS. A copy of the CPS documentation was collected and Referral # recorded as 0299-9947-6594-3092697. The child's contacts were collected.

An exit interview was conducted and a copy of this report was read and provided to Deborah Wilson (Site supervisor), Acting Director on this date.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Aaron MabikaTELEPHONE: (661) 305-7599
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
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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