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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198003493
Report Date: 05/03/2023
Date Signed: 05/03/2023 11:45:53 AM

Document Has Been Signed on 05/03/2023 11:45 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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:MAOF HEAD START ROOSEVELT PARK CENTERFACILITY NUMBER:
198003493
ADMINISTRATOR:ROSA RIOSFACILITY TYPE:
850
ADDRESS:7800 GRAHAM AVE.TELEPHONE:
(323) 584-1250
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 37TOTAL ENROLLED CHILDREN: 30CENSUS: 27DATE:
05/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Lupe CalocaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) T. Tran arrived at MAOF-Roosevelt Park Center to conduct a Case Management inspection that was self-reported on 04/21/2023 regards to a child got injured in the left arm during music and movement activity. Upon arrival, LPA met with Head Teacher, Lupe Caloca and we toured the facility. LPA observed proper care and supervision.

Staff and child file review was completed. LPA obtained the child’s record, LIC 500, staff CPR and First Aid certificate. Interviews were conducted with staff. Due to insufficient information available at this time, the above allegation need further investigation.

No deficiency was cited at this time. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Lupe Caloca.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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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