364809555-5-4-2023-12-CC-EROZ-CRHRN9-20230504130959

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364809555
Report Date: 05/03/2023
Date Signed: 05/04/2023 01:10:02 PM

Document Has Been Signed on 05/04/2023 01:10 PM - 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:	SBCSS GENERAL COLIN L. POWELL STATE PRESCHOOL		FACILITY NUMBER:	364809555
ADMINISTRATOR:	NANCY ALVARADO		FACILITY TYPE:	850
ADDRESS:	37041 RHINELAND DRIVE		TELEPHONE:	(760) 386-7940
CITY:	FT. IRWIN	STATE: CA	ZIP CODE:	92310
CAPACITY:	192	CENSUS: 75	DATE:	05/03/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:14 AM
MET WITH:	Doris Paulino		TIME COMPLETED:	10:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/03/23 at 08:14 a.m. Licensing Program Analyst (LPA) Esequiel Rodriguez conducted a case management inspection at the Facility and met with alternate Site Supervisor, Doris Paulino. The purpose for the inspection was to follow-up on an Unusual Incident Report (UIR) reported to the Department in a timely manner. The incident indicates that (C-1 ) See LIC 811-Confidential Names list, dated 05/03/23, while playing outside in the playground area, and while climbing the stairs to the jungle gym, the minor slipped resulting on injury to the minor's tongue. Janette Rivera, Site Supervisor LPA reviewed C-1 file and obtained medical treatment report. Staff (Ref-1 and Ref-2, See LIC 811-Confidential Names list, dated 05/03/23) were actively providing close supervision to the children at play, and immediately provided basic first aid to C-1, reported the incident and contacted the minor's parents. The child was taken to seek medical assistance. The child is back in care, and is doing well. Per Site Supervisor, everyone at the Facility takes any incident that results in any injury to a child very seriously. Safety of the children in care is a paramount, and is always emphasized. However, there is always a chance for mishaps, and always room for improvement. She stated that the staff present at the time of the incident acted in time, professionally and followed appropriate protocol. There were no safety concerns reported by Ref-3. In the course of the assessment of the incident, LPA Esequiel Rodriguez and LPA Kristina Diaz obtained additional information related to the incident. LPA Rodriguez noted that the incident did happen as reported. However, it did not happen because of negligence or lack of supervision. The incident was an inevitable

SUPERVISOR'S NAME: Scott Herring	TELEPHONE: (661) 202-3314
LICENSING EVALUATOR NAME: Esequiel Rodriguez	TELEPHONE: (661) 202-3321
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SBCSS GENERAL COLIN L. POWELL STATE PRESCHOOL	FACILITY NUMBER: 364809555
	VISIT DATE: 05/03/2023

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accident that the staff providing supervision could not have prevent it from happening.

In the course of the incident investigation, LPA Rodriguez observed no signs of abuse or neglect or wrong doing. All children in care, inside the classrooms as well as in the playground area were properly and closely supervised. Evidence presented indicate the staff present on the day of the incident, acted appropriately, took appropriate immediate action, provided/seek medical assistance for the injured child and reported the incident as expected. The Center is clean, safe, secure, sanitary and orderly. No deficiencies assess during this inspection.

At this time, no further action is required.

Copy of this report, Confidential Names list- LIC 811, and notice of site visit were provided to Ms. Paulino..

SUPERVISOR'S NAME: Scott Herring	TELEPHONE: (661) 202-3314
LICENSING EVALUATOR NAME: Esequiel Rodriguez	TELEPHONE: (661) 202-3321
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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