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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411390
Report Date: 05/11/2022
Date Signed: 05/11/2022 02:49:00 PM

Document Has Been Signed on 05/11/2022 02:49 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:LANCASTER UNITED METHODIST CHILDRENS CENTERFACILITY NUMBER:
197411390
ADMINISTRATOR:DAMON, TAMMYFACILITY TYPE:
830
ADDRESS:918 W. AVE JTELEPHONE:
(661) 942-0812
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 15DATE:
05/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Director Tammy DamonTIME COMPLETED:
03:00 PM
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On May 11, 2022, Licensing Program Analyst (LPA) Brigitte Tsutaoka conducted an unannounced Case Management inspection regarding a self-disclosed incident that occurred 4/26/2022 involving Child 1 (C1) who experienced a seizure at the facility. LPA disclosed the purpose of inspection and was granted entry by Assistant Director, Nicole Medina. Director Tammy Damon guided LPA on a tour of the facility. During inspection, LPA observed 15 infants with 7 staff.

During inspection, LPA conducted staff interviews to obtain statements of what they observed. Based on interviews conducted and records reviewed, C1 was feverish the previous night due to teething and the parent provided Tylenol to keep C1's fever down. Staff provided C1 Tylenol at 10:06AM because C1's fever began to rise. At approximately 1:40, C1's fever was approximately 101 to 102 degrees Fahrenheit. Staff 1 (S1) observed C1 begin to seize and immediately went to the office to notify Director and Assistant Director (AD). Director called 911 and spoke to an emergency dispatcher who instructed staff to lay C1 down on his left side. Staff 2 (S2) held C1 while AD and S2 rubbed his back and chest to gently calm him and verify a heart beat before laying him down on a mat on his left side. Staff ensured to clear the area around the mat to prevent C1 from bumping his head on any surrounding furniture. Staff were not instructed by the emergency dispatcher to perform CPR on the infant. While Director was on the phone with the emergency dispatcher, Parent 1 (P1) arrived at the facility. At approximately 1:50PM, the sheriff arrived then the ambulance arrived. C1 was taken in the ambulance to Antelope Valley Hospital with P1 riding along. P1 disclosed C1 was doing much better. LPA observed C1 at the facility during inspection.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Brigitte Tsutaoka
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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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: LANCASTER UNITED METHODIST CHILDRENS CENTER
FACILITY NUMBER: 197411390
VISIT DATE: 05/11/2022
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Based on evidence collected and interviews conducted, facility staff contacted the appropriate emergency medical responders immediately and provided necessary medical attention to assist C1, promoting the Health and Safety of children in care. The facility is in compliance per Title 22 Regulations and no deficiencies were cited during inspection.

An exit interview was conducted, this Report, Appeal Rights, and Notice of Site Visit were provided to Director, Tammy Damon.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Brigitte Tsutaoka
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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