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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870897
Report Date: 06/15/2023
Date Signed: 06/15/2023 03:48:56 PM

Document Has Been Signed on 06/15/2023 03:48 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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:USC HEAD STARTFACILITY NUMBER:
191870897
ADMINISTRATOR:JOANNA WILLIAMSFACILITY TYPE:
850
ADDRESS:741 WEST 27TH STREETTELEPHONE:
(213) 743-2466
CITY:LOS ANGELESSTATE: CAZIP CODE:
90007
CAPACITY: 119TOTAL ENROLLED CHILDREN: 119CENSUS: 87DATE:
06/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Leticia RodriguezTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) T. Tran and A. Wallin arrived at USC Head Start to conduct a Case Management Incident that was self-reported on 06/07/2023 involved a child in care injured the left arm during an outdoor activity. The Monterey Park Southwest Office received the writing report on 06/08/2023. LPAs met with Leticia Rodriguez, Site Supervisor and we toured the facility. LPAs observed proper care and supervision.

Files review completed for a child and staff. LPA obtained personnel report, child's document, and doctor's note. Interviews were conducted with staff, children, and other. On the day of the incident, there were 19 children with three teachers. Parent was notified of the incident. Based on the available information it does not appear this incident was the result of a Title 22 violation for lack of care and supervision.

No deficiency was cited at this time. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Leticia Rodriguez.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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