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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750081
Report Date: 06/17/2021
Date Signed: 06/17/2021 03:08:25 PM

Document Has Been Signed on 06/17/2021 03:08 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:PURE & SIMPLE ACADEMY & CHILD CARE CENTERFACILITY NUMBER:
197750081
ADMINISTRATOR:AGUIRRE, SANDRA LONAFACILITY TYPE:
850
ADDRESS:43301 DIVISION ST SUITE 101TELEPHONE:
(661) 524-1042
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 45TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
06/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Deborah Castillo, TIME COMPLETED:
03:30 PM
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On 06-17-21, Licensing Program Analyst (LPA) Lady King-Lewis arrived a the facility to conduct a Case Management visit. The purpose of the case management visit was to follow-up on a self reported Unusual Incident Report submitted by the facility on 06-15-21.

During the visit, LPA took a census of the children present, and met with Center Director, Deborah Castillo, to discuss the reported incident. During the visit, LPA spoke with the reported teachers that were in the classroom at the time of the incident when child 1 bit child 2 on the lip. LPA observed child 1 and child 2 in care during this inspection.

LPA received a copy of the Child Care Facility Roster for preschool class # 3 and the attendance sheet for the preschool classroom # 3 and also a copy of staff sign in sheet for 06-14-21.

An exit interview was conducted, a notice of site visit given and informed to be posted for 30 days.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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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