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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700035
Report Date: 07/23/2019
Date Signed: 07/23/2019 01:42:09 PM

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:PERRY FAMILY CHILD CAREFACILITY NUMBER:
367700035
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
07/23/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Ahjenae PerryTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Maddox met with licensee Ahjenae Perry today for the purpose of investigating an Unusual Incident Report (UIR) received 7/15/19. The incident involved 2 day care children ages 11 (child #1) and 4 (child #2). From information gathered, child #2 was sitting on the back of the sofa, licensee asked him to sit on the sofa correctly, child #2 slid down the sofa (on the opposite end of the sofa from child #1) and sat on the cushion, he then got up to play with a wooden kitchen toy sitting in the middle of the day care room, child #1 got up from the sofa and pushed child #2 from behind causing him to fall forward hitting the side of his head on the wooden kitchen set. Licensee went to check on child #2 and noticed he had a cut on the side of his head, the wound was bleeding profusely, she applied pressure to the area and it stopped bleeding. Licensee states she called the parent of child #2 and informed her she was taking child #2 to the Emergency Room at Barstow Community hospital and to meet her there, (licensee also contacted the parent of child #1 and informed her of what happened).

Licensee states on the date of the incident, there were 7 children present (no infants), and her assistant. Further investigation is needed before closing out this UIR.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2019
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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