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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750002
Report Date: 05/03/2021
Date Signed: 05/03/2021 01:20:26 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:OAK TREE LEARNING CENTERFACILITY NUMBER:
367750002
ADMINISTRATOR:CARTER, JENNIFERFACILITY TYPE:
840
ADDRESS:680 W. 40TH STREETTELEPHONE:
(909) 882-6979
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY:48CENSUS: 27DATE:
05/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Katie LewisTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Neal spoke with office staff member, Ms. Katie for the purpose of conducting a follow-up Case Management inspection on an Unusual Incident Report (UIR) from the facility, received by Licensing on 4/19/2021. This incident was self reported.

Description of incident: On Monday 4/19/2021, at approximately 8:40am, during sign-in Child #1 was observed with soft cast on right hand. Staff inquired and it was disclosed that the injury was a dislocated thumb sustained at the center on Thursday 4/15/2021, however Child #1 was unsure about any details of when and where the injury occurred. Staff did not hear any disclosures regarding the incident from Child #1 or observe any incident that led to the injury at the center.

LPA will conduct further follow-up on another date. Exit interview was conducted, report was read and a copy of this report was forwarded to the 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: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
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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