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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197401074
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:45:30 PM

Document Has Been Signed on 10/20/2022 02:45 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:LA PETITE ACADEMY INC.FACILITY NUMBER:
197401074
ADMINISTRATOR:JEANA COURSONFACILITY TYPE:
850
ADDRESS:1709 E. PALMDALE BLVD.TELEPHONE:
(661) 272-3708
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 108TOTAL ENROLLED CHILDREN: 108CENSUS: 91DATE:
10/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:JEANA COURSONTIME COMPLETED:
02:50 PM
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On 10/20/2022 Licensing Program Analyst (LPA) Carol Heath conducted a Case Management- Incident inspection to follow up on an Unusual Incident reported to the department by email on 10/4/2022.

Description of the incident: On 010/04/2022, the facility reported child #1 (4 years old) was complaining of pain in his arm. The director called child #1’s mother. The parents picked up the child and took the child to the hospital. X-ray was taken and it was diagnosed with Nursemaid’s Elbow.

Based on the information gathered and interviews, staff followed their reporting policy and procedure. No citation was issued on this date.

Exit interview was conducted and the report was reviewed with the facility representative Jeana Courson.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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