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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364812586
Report Date: 03/28/2023
Date Signed: 03/28/2023 03:11:53 PM


Document Has Been Signed on 03/28/2023 03:11 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:PSD/ADELANTO HEAD STARTFACILITY NUMBER:
364812586
ADMINISTRATOR:LOVE-FRENCH, LASHAWNFACILITY TYPE:
850
ADDRESS:11497 BARTLETT AVENUETELEPHONE:
(760) 246-5073
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:86CENSUS: 11DATE:
03/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Patricia RosalesTIME COMPLETED:
03:10 PM
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On March 28, 2023, Licensing Program Analyst (LPA) Babatunde Ibitoye met with Site Supervisor Patricia Rosales to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a self reported unusual incident report (UIR) submitted to the Department on December 8, 2022.

Description of incident: On 12/8/2022, around 8:30 am parent of Child Number 1 (C#1) parent notified the center clerk that her child was allegedly injured at the site.Site Supervisor, Patricia Rosales, followed up with the parent regarding her concern. The parent stated she took her daughter to Urgent care last night because she noticed a bruise on her shoulder while showering. When she attempted to lift her arm, the child said it hurt. Per the parent, the child stated she got hurt on the playground Child was under visual supervision the entire time while at the site and there is no indication that an injury occurred. The staff was not aware the child was injured while at the center. When they became aware, the Deputy Director was contacted and a report was filed. The child now has a brace on her arm, the report did not mention the diagnosis

Present during the time of this inspection is the site supervisor, teacher #1,Aide #1 The copy of the facility roster, sign-in and out sheet for the incident day was collected.

Further investigation is needed, An exit interview was conducted, and a copy of this report was read and provided to the site supervisor Patricia Rosales along with a Notice of the Site Visit

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Babatunde IbitoyeTELEPHONE: 661-568-8179
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
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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