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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 03:20:02 PM


Document Has Been Signed on 03/28/2023 03:20 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:
02:20 PM
MET WITH:Patricia RosalesTIME COMPLETED:
03:40 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 March 16, 2023.

Description of incident: On 03/15/2023 at 1:30 PM, Behavior Health Specialist B#1 sat with Child #1 on her lap to prevent C #1 from hurting himself. As C#1 wiggled, C#1 shirt rolled up, exposing C#1 back B #1 observed liner raised scarring on his lower back. C#1 has no language and he cannot say what happened to his back. Program manager P #1 report to child protective services

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.

No Further investigation 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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