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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013578
Report Date: 10/04/2022
Date Signed: 10/04/2022 03:28:51 PM

Document Has Been Signed on 10/04/2022 03:28 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: 15DATE:
10/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Maria Eugenia Hernandez, Site SupervisorTIME COMPLETED:
03:45 PM
NARRATIVE
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On October 4, 2022, Licensing Program Analysts (LPAs) Monique Ayala and Veronica Martinez-Garza conducted an unannounced case management inspection to follow up on an Unusual Incident Report that filed with the department on 09/28/2022. A COVID-19 risk assessment was conducted prior to entering the facility. Upon arrival LPAs were greeted by site supervisor, Maria Eugenia Hernandez who guided LPAs on a tour of the facility. LPAs observed 15 children in care.

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 inspection, LPAs interviewed, staff #1, staff #2, child #1, parent #1, obtained a copy of internal incident report, sign in and out sheet of child #1 and current facility roster.

At this time this case management required further investigation.

The facility is being cited a Type B deficiency for Reporting Requirements. The incident occurred on 09/21/2022 and was reported to the department on 09/28/2022. Please see LIC809D.

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: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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Document Has Been Signed on 10/04/2022 03:28 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 10/04/2022 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: VOLUNTEERS OF AMERICA, AZTECA HEAD START
FACILITY NUMBER: 198013578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2022
Section Cited
CCR
101212(d)(1)(B)

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Reporting Requirements: Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours ...
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Site supervisor stated all incidents will be reported withing regulation timeframe.
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 Any injury to any child that requires medical treatment. This requirement was not met as evidence by: Based on record review site supervisor report incident 7 days after the incident occurred. This poses a potential health and safety risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022


LIC809 (FAS) - (06/04)
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