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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191670974
Report Date: 09/30/2022
Date Signed: 09/30/2022 11:28:24 AM

Document Has Been Signed on 09/30/2022 11:28 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:LBUSD-MANN CHILD DEVELOPMENT CENTERFACILITY NUMBER:
191670974
ADMINISTRATOR:ROBBIE WADELLFACILITY TYPE:
850
ADDRESS:3215 E VISTA AVETELEPHONE:
(562) 439-7896
CITY:LONG BEACHSTATE: CAZIP CODE:
90803
CAPACITY: 48TOTAL ENROLLED CHILDREN: 23CENSUS: 21DATE:
09/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nancy Perez, Coordinating TeacherTIME COMPLETED:
12:00 PM
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On 09/30/2022 at 11:00 AM, Licensing Program Analyst (LPA) Katrina Chicote conducted an unannounced case management inspection to follow up on an incident that occurred on 09/20/2022. LPA met with Nancy Perez, Coordinating Teacher (CT), who guided LPA on a tour of the facility. There were 21 children and five staff present upon arrival. LPA observed children and staff were outside during inspection.

LPA conducted interviews and obtained documentation during this visit.

The incident that occurred on 09/20/2022, was reported to the Department on 09/20/2022, via telephone. A written report was received via email the same day. Reporting requirements met per Title 22 Regulation requirements.

Information received by The Department indicated that C1 was playing on the play structure and hit the back of his head. Staff was present and witnessed incident occur and provided immediate assistance. Child was provided ice pack and sat in lobby until mom was available to pick up. Per CT, she called 911 after observing that C1 was nauseous and wanting to vomit and observed to be yawning. Paramedics arrived and observed child and cleared C1 to go home with mom. CT followed up with mom later that day, who informed CT that they did take C1 to Urgent Care where he was evaluated and cleared to return home. Per CT, C1 stayed home another day but has now returned to school.

LPA observed structure where incident occurred during inspection and observed two staff members supervising area at time of inspection. LPA observed C1 at facility during inspection.

Based upon information from the interview conducted and observations made, it was determined that there were no Title 22 violations in regards to incident. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Coordinating Teacher, Nancy Perez.
Report Ends - Page 1 of 1
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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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