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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197401581
Report Date: 04/06/2023
Date Signed: 04/06/2023 11:25:49 AM

Document Has Been Signed on 04/06/2023 11:25 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:ANTELOPE VALLEY COLLEGE CHILD DEV. CENTERFACILITY NUMBER:
197401581
ADMINISTRATOR:ORLIC-BABIC, KATARINAFACILITY TYPE:
850
ADDRESS:3041 WEST AVENUE KTELEPHONE:
(661) 722-6500
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 36DATE:
04/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Angelica Alvarez, Program SpecialistTIME COMPLETED:
11:35 AM
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On 04/06/23, Licensing Program Analyst (LPA) Justeene Tamayo met with Program Specialist Angelica Alvarez who guided LPA on a tour of the facility. The purpose of this visit was to conduct a Case Management - Incident Follow Up Inspection for two Unusual Incidents that occurred on 03/02/23 and 03/21/23. The Unusual Incidents were self reported within the time frame specified by regulations. Upon arrival, LPA observed 36 preschool children in care with 8 staff present, and the Program Specialist.

LPA Tamayo followed up with staff and children involved regarding incident #1 and incident #2.

Description of incident #1: On 03/02/23, child #1 fell on the dirt while running outside with a friend. Child #1 tripped on child #2 foot. Child #1 got up and brushed self off. Staff #1 asked if child #1 was okay and child #1 responded they were okay. Staff #1 and staff #2 did not observe bruises, blood or scratches. On 03/03/23, child #1 arrived to school with a brace on the wrist and child #1 explained they fell at home.

Description of incident #2: On 03/21/23 at approximately 10:40 AM, child #1 placed hand on the table and another hand on the shelf. Child #1 lifted his body to swing his legs. Child #1 lost hold of the table and fell hitting his chin on the floor. Child #1 chin started bleeding and needed medical attention.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ANTELOPE VALLEY COLLEGE CHILD DEV. CENTER
FACILITY NUMBER: 197401581
VISIT DATE: 04/06/2023
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After interviews conducted, it was revealed both incidents were accidental. Staff had witnessed both incidents, and took appropriate measures to ensure the health and safety of each child. No deficiencies are being cited at this time.

An exit interview was conducted and a copy of this report was provided to the Program Specialist, along with Notice of Site Visit and appeal rights.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC809 (FAS) - (06/04)
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