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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364830080
Report Date: 09/13/2019
Date Signed: 09/13/2019 10:41:55 AM

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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
364830080
ADMINISTRATOR:BRIANNE HINDMANFACILITY TYPE:
850
ADDRESS:13615 BEAR VALLEY ROADTELEPHONE:
(760) 949-8539
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:88CENSUS: 52DATE:
09/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Samantha BrownTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Neal met with Assistant Director, Samantha Brown, today for the purpose of Case Management follow-up inspection of an Unusual Incident Report (UIR) that was reported to Licensing on 9/4/2019. This UIR was self-reported.

Description of the incident: On 9/3/2019, two children were playing on the carpet in the preschool classroom and Child #1's arm was pulled by another child. Afterwards, Child #1's wrist began to swell. An ice pack was applied to Child #1's wrist and parent was notified. Medical treatment was sought by parent and staff was notified that Child #1 sustained a bruise.

During this investigation, LPA spoke with staff, interviewed Child #1 (present at the center) and reviewed child's file which included an Incident/Accident Report signed by the parent on 9/3/2019. Based on information provided, staff present at the time of the incident and interviews conducted no further investigation is needed at this time. Notice of Site visit was given to be posted for 30 days.
An exit interview was conducted and a copy of this report was read and provided to the assistant director on this date.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Jazelle NealTELEPHONE: (661) 568-8945
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019
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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