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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601484
Report Date: 06/13/2023
Date Signed: 06/13/2023 11:56:21 AM

Document Has Been Signed on 06/13/2023 11:56 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 EDUCATIONFACILITY NUMBER:
191601484
ADMINISTRATOR:AMY AGNEWFACILITY TYPE:
850
ADDRESS:101 S. BELLAGIO DR.TELEPHONE:
(310) 825-5086
CITY:LOS ANGELESSTATE: CAZIP CODE:
90095
CAPACITY: 122TOTAL ENROLLED CHILDREN: 122CENSUS: 85DATE:
06/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:AMY AGNEW, DIRECTORTIME COMPLETED:
12:10 PM
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On 6/13/2023, Licensing Program Analyst (LPA) Loyce Phillips, conducted a case management inspection to follow up on an Unusual Incident, reported to the department by telephone on 6/6/2023. LPA was greeted by Director, Amy Agnew. LPA toured the facility and took a census of the children. Upon arrival, there were 85 children and 17 staff present today at the facility.

Description of the incident: On 6/1/2023 at approximately 4:40pm, C1 was running on the play yard when he tripped over his feet. Child fell and caught himself by the hand. Staff applied ice and parent arrived during incident. Parent arrived to the facility at 4:45pm and took child to UCLA urgent care; X-rays confirmed child had a fracture thumb. On 6/2/2023, parent took child to the Orthopedic Institute where a cast was placed on child's right thumb. On 6/5/2023, child returned back to the facility with restrictions.

During this inspection, LPA toured the facility, interviewed staff, obtained pertinent documents, a copy of classroom roster and inspected the outdoor play area.

Based on the information provided and interviews conducted further investigation is required.

An exit interview was conducted, a copy of this report and notice of site visit was provided to Director.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Loyce Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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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