191601484-11-4-2022-58-CC-DMIA-CKUPZJ-20221104114537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191601484
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:45:42 AM

Document Has Been Signed on 11/04/2022 11:45 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	UCLA EARLY CARE AND EDUCATION		FACILITY NUMBER:	191601484
ADMINISTRATOR:	AMY AGNEW		FACILITY TYPE:	850
ADDRESS:	101 S. BELLAGIO DR.		TELEPHONE:	(310) 825-5086
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90095
CAPACITY:	122	CENSUS:	DATE:	11/04/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rosaura Castillo, Center Coordinador and Amy Agnew, Director		TIME COMPLETED:	11:55 AM

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	On 11/04/2022, 9:30:AM Licensing Program Analyst (LPA) Denise Miranda conducted an unannounced case management inspection to the facility to follow up on the self-reported unusual incident that occurred on 09/13/2022. LPA observed 74 children preschool being supervised by 15 staff. LPA met with Rosaura Castillo, Center Coordinator and informed the purpose of the visit. Director arrived at 11:05am and informed the purpose of the visit. Facility reported this incident to the facility# 191601954 – Infant care. During this inspection, a revised LIC624 Unusual Incident Report was provided to LPA Miranda showing the correct facility #191601484. According to the incident report received, on 09/13/2022, child #1 was standing by the door, on the hinge side when a parent walked in. Child #1 stuck his three, middle, right hand fingers in the hinge side opening and his fingers got smashed by the door when it closed. Staff#1 quickly went over to release his fingers. She washed the area with water and soap and applied ice. His fingers bruised and there was broken skin. LPA obtained a copy of Child Care Facility Roster, sign in and out dated 09/13/2022, Doctor’s child's notes, Staff time card for the day when this incident happened, photos of the door area, LPA reviewed the Staff files that were involved on this incident and child#1 file, they are completed. LPA conducted interviews with the staff, child’s parent. LPA was unable to interview child#1 that was not present during this visit. At the time of the incident that occurred, teacher to child ratios were within compliance. Facility staff provided proper care and supervision during the time of

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise Miranda	TELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: UCLA EARLY CARE AND EDUCATION	FACILITY NUMBER: 191601484
	VISIT DATE: 11/04/2022

NARRATIVE

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the incident facility had two fully qualify teachers with 9 children in care. Facility applied first aid immediately. This incident happened during the pick up time and mother of the child was notified, ouch report were provide to mother of the child#1 and sought medical assistance after the incident. The child remains enrolled in the above day care.
LPA observed that Facility placed a red tape on the floor by the door, that will help the children in care do not cross that area without staff permission avoid them to stand by the door. Facility spoke with the children in care and children’s parents regarding the door area.
Based on the information obtained throughout the course of the investigation, it does not appear that the incident was a result of a Title 22 violation. The facility also followed Title 22 Regulations in the care and supervision of the children and reporting the incident to the Community Care Licensing Division.

An exit interview was conducted and a copy of this report along with the Notice of Site Visit were provided to Amy Agnew, Director.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise Miranda	TELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC809 (FAS) - (06/04)

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