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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870897
Report Date: 10/19/2023
Date Signed: 10/19/2023 03:40:58 PM

Document Has Been Signed on 10/19/2023 03:40 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 SW RO, 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:
2137432466
CITY:LOS ANGELESSTATE: CAZIP CODE:
90007
CAPACITY: 119TOTAL ENROLLED CHILDREN: 104CENSUS: 85DATE:
10/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Leticia RodriguezTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) T. Tran made an unannounced visit at USC Head Start to follow up self-reported incident occurred on 09/26/2023 regards a child had an injury while in care. The Monterey Park Southwest Office received the writing report on 10/03/2023. Upon arrival, LPA met with Leticia Rodriguez, Site Supervisor and we toured the facility. LPA observed children were napping no concern with the level of care and supervision.

LPA completed children and staff files review. LPA obtained personnel report, child's document, doctor's note, and other support document. Interviews were conducted with staff, children, and other. On the day of the incident, there were 16 children with two 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: Denise Gibbs
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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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