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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750040
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:32:37 PM

Document Has Been Signed on 11/03/2022 02:32 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:PALMDALE SCHOOL DISTRICT - DO HEAD STARTFACILITY NUMBER:
197750040
ADMINISTRATOR:DR. MELANIE CULVERFACILITY TYPE:
850
ADDRESS:975 EAST AVENUE P-8TELEPHONE:
(661) 266-7864
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 15TOTAL ENROLLED CHILDREN: 15CENSUS: 9DATE:
11/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:24 PM
MET WITH:Joe Vega-Smith.TIME COMPLETED:
02:35 PM
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On 10/13/2022 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 04/21/2022. LPA Justin Dorsey received LIC 624 (UIR).

Description of the incident: On 02/20/2021 at approximately 10:15 AM. A teacher reported child 1 (4 years old) was crying and cradling her left arm. LVN-Agraz went to the classroom to check on the child and child #1 was grimacing due to the discomfort. RN-Ermilio was called to check the child and determined that child #1 should be seen at the hospital. Child #1’s mother was called around 10:30 am and the child’s father picked up the child around 10:55 am. The child was seen at Palmdale Regional Medical Center.

Based on IB’s investigation, there is not a preponderance of the evidence to prove that Child #1 was an injury in the school; therefore, the above allegation is Unsubstatation.

No Deficiencies were cited.

Appeal Rights were provided and discussed with the facility representative Melanie Culver / Joe Vega-Smith.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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