<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013578
Report Date: 10/13/2022
Date Signed: 10/13/2022 02:24:51 PM

Document Has Been Signed on 10/13/2022 02:24 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:VOLUNTEERS OF AMERICA, AZTECA HEAD STARTFACILITY NUMBER:
198013578
ADMINISTRATOR:ROKEYA RAHMANFACILITY TYPE:
850
ADDRESS:522 DANGLER AVENUETELEPHONE:
(323) 780-3770
CITY:LOS ANGELESSTATE: CAZIP CODE:
90022
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 13DATE:
10/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Maria Hernandez, Site SupervisorTIME COMPLETED:
02:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On October 13, 2022 at 2:05PM, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced case management inspection at the above facility. A COVID-19 risk assessment was conducted prior to entering the facility. LPA met with Site Supervisor, Maria Hernandez who guided LPA on a tour of the facility. LPA observed 13 children in care with 4 staff.

Brief Summary of Incident: On 9/21/22 at 9:55 am, during outside time at the playground, child #1 (C1) climbed the slide and instead of going down the slide, C1 decided to jump down. C1 fell, landing his body on top of his left arm. At first the child was crying but when the teacher applied an ice pack to the affected area and read a book, the child stopped crying. C1's mother arrived 10 minutes later.

During this investigation, LPA interviewed, staff #1 (S1), staff #2 (S2), staff #3 (S3), child #1 (C1), parent #1 (P1), obtained a copy of internal incident report, sign in and out sheet of C1 and current facility roster.

Per S3, S3 was approximately 9 feet away from C1 when the incident occurred. S3 stated C1 jumped and landed on the soft cushioned blue material (padding) on C1's left side where C1's left arm was under his body. S3 stated C1 got up and ran around the play structure until he came back to the area where he feel and saw S3. S3 stated that when C1 saw her, C1 started to cry while holding his left arm. S3 took C1 to S2 informing S2 about the incident. S2 took C1 to S1 who applied an ice pack on C1 and notified P1 of the incident. C1 was picked up from the facility within 10 minutes of the incident and taken to urgent care. As a result of the incident C1 had a broken left elbow which required surgery.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: VOLUNTEERS OF AMERICA, AZTECA HEAD START
FACILITY NUMBER: 198013578
VISIT DATE: 10/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
There are no deficiencies being cited as this was an incident that occurred fast and was unable to be prevented. Per S3 she witnessed the incident occur and took the proper measures to ensure C1 received the proper first aid care.

LPA observed the play structure to be age appropriate for preschool age children, LPA observed the cushioned material (padding) to be in good repair, LPA observed sign in sheets for children and staff of the day of incident and found the facility to be in ratio. This incident was an accident.

An exit interview was conducted and a copy of this report was provided to site supervisor along with Notice of Site Visit and appeal rights.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2