191201899-10-18-2023-12-CC-APIN-CWQS94-20231018134007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191201899
Report Date: 10/18/2023
Date Signed: 10/18/2023 01:41:28 PM

Document Has Been Signed on 10/18/2023 01:41 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	LANCASTER UNITED METHODIST CHURCH PRE SCHOOL		FACILITY NUMBER:	191201899
ADMINISTRATOR:	MEDINA, NICOLE		FACILITY TYPE:	850
ADDRESS:	918 WEST AVENUE J		TELEPHONE:	(661) 942-0812
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY: 58	TOTAL ENROLLED CHILDREN: 58	CENSUS: 35	DATE:	10/18/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Director Nicole Medina		TIME COMPLETED:	01:50 PM

NARRATIVE

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On 10/18/2023 at 9:47am, Licensing Program Analyst (LPA) Andrea Pittman conducted an unannounced case management visit at the facility and was met by the Director Nicole Medina who permitted entry to the facility. LPA toured the facility with the Director according to the facility sketch. Upon arrival, LPA observed 35 children with 8 staff members providing care and supervision.

On 10/12/2023, the Director reported an Unusual Incident to the office via phone stating that Child 1 had inappropriate contact with Child 3. After observations, interviews, and record reviews, the following information was revealed about the incident which led to the submission of the unusual incident report:

During this investigation, LPA received pertinent information regarding the investigation. It was revealed that Child 3 was playing on the side of the climbing structure, hanging from a bar. Child 1 was playing and fell into Child 3. It was during the fall that Child 1 made incidental contact with Child 3.

The unusual incident was followed up and it was determined that there was no violation that occurred in this incident. The facility acted in accordance to Title 22 Regulations. The facility is encouraged to continue to report unusual incidents.

An exit interview was conducted, and a copy of this report was read and provided to Director Nicole Medina along with the Notice of Site Visit and Appeal Rights.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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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