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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191606358
Report Date: 09/26/2022
Date Signed: 05/02/2023 08:49:33 AM

Document Has Been Signed on 05/02/2023 08:49 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:SAMUEL GOLDWYN FOUNDATION CHILDREN'S CENTERFACILITY NUMBER:
191606358
ADMINISTRATOR:KAE CONNORSFACILITY TYPE:
850
ADDRESS:2114 PONTIUS AVENUETELEPHONE:
(310) 445-8993
CITY:LOS ANGELESSTATE: CAZIP CODE:
90025
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 34DATE:
09/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Summer Saito, Health and Safety DirectorTIME COMPLETED:
11:15 AM
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On 9/26/2022 Licensing Program Analyst (LPA) Judy Laureano arrived at Samuel Goldwyn Foundation Children's Center for a Case Management Incident Inspection to follow up on the self-reported incident that occurred on 9/14/2022. Incident was reported to the El Segundo Child Care Regional Office on 9/16/2022.

Child was playing on the preschool playgound. Two teachers were outside providing care and supervision to 16 children. Child was climbing down, she tripped and fell on the area coming from the sand area to the soft area, landing on her left side.

Teacher applied ice to the area and observed child not moving her forearm and parent was called. Parent picked up child and stated she will be taking child to the doctor. Facility called to follow up with parent. Parent informed facility that child had a fracture in her forearm. Child was placed in a cast and was back in care on 9/16/2022.

Based on the information obtained throughout the course of the investigation it does not appear that the incident was a result of Title 22 violation. Facility/staff are following the proper protocol to ensure the health and safety of the children.

Exit interview was completed and a Notice of Site Visit and report was provided to Summer Saito.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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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