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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364808716
Report Date: 12/13/2019
Date Signed: 12/13/2019 01:30:05 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:AVUSD SANDIA STATE PRESCHOOLFACILITY NUMBER:
364808716
ADMINISTRATOR:PETE RODINE, ED.D.FACILITY TYPE:
850
ADDRESS:21331 SANDIATELEPHONE:
(760) 240-3155
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:48CENSUS: 17DATE:
12/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Leandra Figueroa Site SupervisorTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Steven Montoya conducted a unannounced inspection at the Sandia Academy Pre school facility and met with Site Supervisor (SS) Leandra Figueroa regarding an Unusual Incident Report (UIR) dated: 11-22-2019. See Confidential Name Form (LIC 811)

Unusual Incident Report reads as:
Reporting Party (RP) who is the SS, reports, on Thursday 11-21-2019 @ 3:00 PM, the Child # 1 was playing outside on the play structure, he walked up the stairs, proceeded to walk on th walk way when he tripped and fell. Child # 1 bumped his mouth on the ground hurting his upper front teeth. Child had a noticable bleeding on mouth and was given immediate first aid by T # 1 along with the ice pack. Teacher contacted parents (spoke to dad) while first aid was given. RP took child to the nurse, where the nurse confirmed child's upper right front tooth was loose. Incident happened 1 day before Thanksgiving break; It is unclear if parents intend to seek medical/ dental treatment for child. The teacher will continue to assigned to stand post at the play structure to assist and help any children on play structure.

The investigation will consist of interviews with one staff, parent and alleged victim and review of supportive documents. Based on the interviews and absences of primary witness. Further investigation is required in order to obtain evidence to prove that the facility meets reporting requirements according to Title 5 regulations. Exit interview conducted and a copy of the report was left with the Site Supervisor.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (661) 568-8932
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2019
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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