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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 143808560
Report Date: 11/06/2024
Date Signed: 11/06/2024 11:07:24 AM

Document Has Been Signed on 11/06/2024 11:07 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:ICSS - WEST BISHOP STATE PRESCHOOLFACILITY NUMBER:
143808560
ADMINISTRATOR/
DIRECTOR:		KAT DUNCANFACILITY TYPE:
850
ADDRESS:164 GRANDVIEW DRIVETELEPHONE:
(760) 873-5123
CITY:BISHOPSTATE: CAZIP CODE:
93514
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 9DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:44 AM
MET WITH:Kila Miller, Special Ed Lead TeacherTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On November 6, 2024, Licensing Program Analyst (LPA) Crystal Ali met with Kila Miller, special ed lead teacher/site supervisor, conduct an unannounced case management inspection. The purpose of the case management (CM) was to follow up on unusual incident report (UIR) 10/29/24. UIR was received 10/29/24.

On 10/29/24 at approximately 9:30am, child#1 was holding two toys in her hands and tripped over her own feet and fell on her elbows. The child then got up and continued to play. Then 15 minutes, she was unable to lift her right arm. Teacher notified the parent immediately. Parent took child to hospital and was diagnosed with dislocated right elbow. Child has not returned to preschool at this time.

Upon arrival, LPA observed 9 preschool and 6 staff member providing care.

During this inspection LPA reviewed LIC 9040 and interviewed staff regarding the incident.
No deficiencies have been cited at this time.

Exit interview conducted with Kila Miller and Notice of Site Visit. Notice of site visit must remain posted for 30 days.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Crystal Ali
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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