<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195700031
Report Date: 05/21/2024
Date Signed: 05/21/2024 11:33:10 AM


Document Has Been Signed on 05/21/2024 11:33 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:BOULEVARD SCHOOL, THEFACILITY NUMBER:
195700031
ADMINISTRATOR:JENNIFER WILLFACILITY TYPE:
850
ADDRESS:23022 VICTORY BLVDTELEPHONE:
(818) 883-0607
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:203CENSUS: DATE:
05/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Jennifer WillTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tatiana Bickham conducted an unannounced case management inspection due to an incident that occurred on 5/8/2024. LPA arrived at the facility at 9:08 AM and met with Director, Jennifer Will, who guided LPA on a tour of the facility. There were 142 children and 19 staff present upon arrival.

The incident that occurred on 05/08/2024, was reported to the Department on 05/08/2024, via telephone. The facility reported the Unusual Incident to the Department within the required 24 hours of occurrence.

Description of the incident: C1 was playing on monkey bars when one hand missed the bar and child fell down. Two teachers were monitoring the playground but did not see when C1 fell, only saw her when she was on the ground. Teacher brought C1 to the office and put an icepack on her elbow and called mom. Mom took child to the hospital and C1 has a broken elbow, had surgery and has a cast on her arm. C1 has a doctors note and will be out until May 27th.

Information reported to the Department indicated that staff did not provide adequate supervision resulting in Child#1 falling off the monkey bars and breaking a bone.

Based on interviews, and statements, it was determined nothing could have been done to prevent Child #1 from falling and obtaining an injury.

No deficiencies were cited during today's visit. Notice of site visit must be posted for 30 days.

Exit interview was conducted and report was giving to Director, Jennifer Will.
SUPERVISOR'S NAME: Raul NavarroTELEPHONE: (424) -30-3072
LICENSING EVALUATOR NAME: Tatiana BickhamTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1