<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414100
Report Date: 03/16/2022
Date Signed: 03/16/2022 01:37:40 PM


Document Has Been Signed on 03/16/2022 01:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:CREATIVE EXPLORERSFACILITY NUMBER:
434414100
ADMINISTRATOR:DARCY HELLUMSFACILITY TYPE:
850
ADDRESS:604 E. EVELYN AVE.TELEPHONE:
(408) 685-2863
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:45CENSUS: DATE:
03/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Darcy HellumsTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mel Matos met with Darcy Hellums, owner/director, for an unannounced case management inspection. Purpose of today's inspection: discuss an Unusual Injury that the Facility self reported to the Department.

The Unusual Injury occurred on March 9, 2022 at approximately 4:50 PM. Two preschool children were playing on the monkey bars in the outdoor playground and were repeatedly dropping off the monkey bars upon reaching the middle point of the bars. Darcy states that two children were doing this as part of a game that both were playing. Darcy states that one of the preschool fell onto the child's left elbow after one sequence. Darcy states that there were four preschool children and one teacher in the playground at the time of the incident.

Darcy states that the child's left elbow was iced and checked for any visible injuries. Darcy states that there were no visible signs of swelling and that the child had complete movement of the child's arm. Darcy states that the child's mother was advised of the incident upon arrival to pick up the child.

Darcy states that the child was taken to see a doctor on March 10, 2022 and was diagnosed with a fracture on the child's left elbow. Darcy states that the child got a cast on the child's left arm on March 11, 2022. Darcy states that the child returned to the Facility on March 15, 2022 and is doing fine. LPA toured the preschool outdoor playground during today's inspection and concluded that the monkey bars are age appropriate and that there is sufficient resilient materials in the playground.

No deficiencies issued during today's inspection. Exit interview conducted and report was reviewed with Darcy Hellums, Owner/Director. A notice of site visit was given and must remain posted adjacent to the main door for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1