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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364813684
Report Date: 01/28/2021
Date Signed: 01/28/2021 03:47:18 PM

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:KIDCARE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
364813684
ADMINISTRATOR:JUNE BOWMANFACILITY TYPE:
840
ADDRESS:15025 GRAVILLA ROADTELEPHONE:
(760) 955-6466
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:14CENSUS: 6DATE:
01/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Carmen RodriguezTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Neal met with Assistant DIrector, Carmen Rodriguez via Tele-Visit today for the purpose of a Case Management inspection of an Unusual Incident self-reported by the facility and received by Licensing on 1/25/2021.

Description of the incident: On 1/22/2021, Child #1's parent reported to staff that Child #1 disclosed allegation that Staff #1 pulled his ears.

During this investigation, LPA interviewed children and staff as well as requested roster of children present. Based on information obtained, further investigation is needed. Exit interview was conducted and a copy of this report was forwarded to the Assistant Director via email for confirmation with “Read Receipt” on this date.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Jazelle NealTELEPHONE: (661) 568-8945
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
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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