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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750130
Report Date: 09/07/2022
Date Signed: 09/07/2022 02:17:59 PM

Document Has Been Signed on 09/07/2022 02:17 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 INC.FACILITY NUMBER:
197750130
ADMINISTRATOR:SANDRA LONA AGUIRREFACILITY TYPE:
830
ADDRESS:43301 DIVISION ST. SUITE 101TELEPHONE:
(661) 524-1042
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 58TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
09/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Sandra Lona Aguirre Licensee TIME COMPLETED:
02:20 PM
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Licensing Program Analysts (LPAs) King-Lewis and Alemoh arrived at the facility to conduct a Case Management visit on a self-reported Unusual Incident Report received by Community Care Licensing on 08/30/22. LPA met with licensee Sandra Lona Aguirre, Director Debbie Castillo, and interviewed staff members, parent of infant, reviewed child file for the infant needs and service plan, the safe sleep documentarians and other documents.

It was disclosed that when the infant showed signs of flush/discolored hands and feet, licensee call 911 and director simultaneously called infant parent. LPA informed licensee that the incident report received stated the parent of the infant was called and the parent of the infant told staff to call 911. LPA received an amended incident report during this visit. No citation issue during this visit.

An exit interview was conducted, appeal rights discussed, a copy of form LIC9224, Notice of Site Visit, and a copy of this report was provided to Sandra Lona Aguirre licensee on this date.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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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