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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364840739
Report Date: 03/05/2020
Date Signed: 03/05/2020 03:34:15 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:PSD/NORTHGATE HEAD STAR/STATE PRESCHOOLFACILITY NUMBER:
364840739
ADMINISTRATOR:STEPHANIE RODRIGUEZFACILITY TYPE:
850
ADDRESS:17251 DANTE STREETTELEPHONE:
(760) 951-1425
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:32CENSUS: 25DATE:
03/05/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Stephanie HernandezTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Neal met with Director, Stephanie Hernandez and conducted a Case Management Incident inspection for an Unusual Incident Report dated 3/5/2020. This incident was self-reported.

Description of Incident: On 3/4/2020 at 9:45am, Child #1 was playing on the playground structure, began to jump off the ladder side and fell with a leg on each side of the metal stair bar which caused Child #1 to hit their private area. 2 teachers were present and observed the incident. Child was taken to the bathroom, first aid was applied, parent was notified at 9:50am and child was picked up around 10:11am. Medical attention was sought by parent and child has returned to school the following day.

During today's inspection, LPA conducted interviews and reviewed Child Incident Report. Playground was inspected. LPA observed no loose, broken or sharp parts on the play structure (age appropriate) or tripping hazards. Based on review of the actions taken by the facility, interviews and other information obtained, no additional follow up will be required at this time. No deficiencies were cited.

Exit interview was conducted, report was read and a copy was provided to the director.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Jazelle NealTELEPHONE: (661) 568-8945
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
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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