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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495434
Report Date: 01/31/2025
Date Signed: 01/31/2025 11:10:24 AM

Document Has Been Signed on 01/31/2025 11:10 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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:CCRC SHERWOODFACILITY NUMBER:
197495434
ADMINISTRATOR/
DIRECTOR:		KRYSTAL WADEFACILITY TYPE:
860
ADDRESS:7224 WOODLEY AVETELEPHONE:
(818) 997-1077
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 49TOTAL ENROLLED CHILDREN: 38CENSUS: 31DATE:
01/31/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:55 AM
MET WITH:Lead Teacher Jennifer LopezTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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On 1/31/25 at 7:55am, Licensing Program Analyst (LPA) Jeanine Lipsey conducted an unannounced, in-person Case management incident inspection. The incident was reported to Community Care Licensing on 1/16/25 via phone. The facility reported the Unusual Incident to the Department within the required 24 hours of occurrence. The incident occurred on 1/15/25.

Incident: A child fell over a tricycle and hit his forehead on the ground.

Upon arrival, LPA was guided on a tour of the facility by Lead Teacher Jennifer Lopez to whom the purpose of the inspection was announced.

Census: There were thirty one children being supervised by six staff.

During the inspection, LPA obtained a copy of the facility roster, Personnel Association Roster, the doctors report the child's medical diagnosis, and conducted an interview with the director and 1 staff, took photos and made observations of the tricycle and the area where the incident occurred.

LPA observed that the playground surface is maintained and in good condition.

Per Staff #1 (S1), there were six children on the play yard playing, being supervised by two staff. S1 was sitting on the table in front of the track and staff #2 (S2) was standing on the other side of the track observing the children. The child fell a few feet in front of S2. Child #1 (C1) was running parallel to Child #2 (C2) while they were riding the tricycle around the track. The track is an outer circle and an inner circle designated for riding the tricycles. C2 was riding the tricycle and C1 darted in front of C2 which caused the child to fall and hit their forehead on the ground sustaining bruise. The bruise was a small red bump in the middle of the forehead. S1 washed the area and applied an ice pack. Incident occurred at 11:19am, the parent was notified at 11:22am via telephone by called by the Family Advocate (FA). The parent picked up the child at 12:15pm, was given a doctor’s referral and took the child to the hospital.
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CCRC SHERWOOD
FACILITY NUMBER: 197495434
VISIT DATE: 01/31/2025
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Child returned to school on 1/23/25. Per Director, Child#1 is fine and did not have any restrictions to return to school.

During today’s visit, LPA and Director discussed creating a plan of correction to ensure that the moving forward, this type of incident could be prevented. The director stated the children are always supervised to prevent accidents and this was a one time occurrence, however, Staff will continue to observe the children as they play.

Exit interview conducted and report was reviewed with Director Kyrstal Wade. A Notice of Site Visit was given and must remain posted for 30 days.




The department finds there was not a deficiency in compliance.
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC809 (FAS) - (06/04)
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