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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364809555
Report Date: 09/12/2019
Date Signed: 10/29/2021 04:20:32 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:SBCSS GENERAL COLIN L. POWELL STATE PRESCHOOLFACILITY NUMBER:
364809555
ADMINISTRATOR:JANETTE RIVERAFACILITY TYPE:
850
ADDRESS:37041 RHINELAND DRIVETELEPHONE:
(760) 386-7940
CITY:FT. IRWINSTATE: CAZIP CODE:
92310
CAPACITY:192CENSUS: 65DATE:
09/12/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Jeanette Rivera, Site SupervisorTIME COMPLETED:
01:00 PM
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LPA Montoya and Maddox met with Site Supervisor Jeanette Rivera for the purpose of investigating 2 Unusual Incident Reports.

The first UIR involved child #1. From Information gathered, On Monday, 8/26/19, mother of child #1 arrived at the center at approximately 11:45 and reported her child was injured at the center on Friday, August 23, 2019. Parent stated another day care child (child #2) hit her son on his thigh (unsure exactly which thigh) and sustained a bruise. Mother stated she filed a report with the Military Police regarding the injury. There is no record child required any medical attention. During this inspection, LPA's interviewed staff who all stated they didn't observe child being hit or injured. Child #1 was also interviewed and doesn't recall being hurt or injured. No further action is required at this time.


SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: SBCSS GENERAL COLIN L. POWELL STATE PRESCHOOL
FACILITY NUMBER: 364809555
VISIT DATE: 09/12/2019
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The second UIR involved child #3. From Information gathered, On 10-31-2018, child # 3 fell from a small artificial rock climber on the play yard. Child was comforted and no visible injury was observed. Child seemed fine and continued playing. Mother returned 45 mins later and said child was hurt in private area and would be taking her to emergency. Child # was taken to doctor and cleared to return on 11-2-2018. During this inspection, picture was taken of the Rock climber on the yard. Medical report was reviewed and there appears to be no evidence of inappropriate activities or intentional infliction of pain. No Further action is required at this time.

Exit interview conducted, copy of report read, signed, and distributed to Site Supervisor during this inspection.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2019
LIC809 (FAS) - (06/04)
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