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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015475
Report Date: 03/14/2022
Date Signed: 03/14/2022 03:53:49 PM

Document Has Been Signed on 03/14/2022 03:53 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:JOHN W. MACK CENTER, USC HEAD STARTFACILITY NUMBER:
198015475
ADMINISTRATOR:DEBBIE GIPSONFACILITY TYPE:
850
ADDRESS:3020 SOUTH CATALINA STREETTELEPHONE:
(213) 743-4651
CITY:LOS ANGELESSTATE: CAZIP CODE:
90007
CAPACITY: 45TOTAL ENROLLED CHILDREN: 30CENSUS: 24DATE:
03/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Joanna Williams, Associate DirectorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) T. Tran arrived at the above licensed facility to conduct an unannounced Case Management Incident. The Monterey Park South West Child Care Regional Office received the incident report on 2/18/22022 regarding a child running at the playground area and tripped landed on the left wrist. Upon arrival, LPA observed proper care and supervision. LPA met with Joanna Williams, Associate Director and Kenicia Mota, Site Supervisor.

LPA completed staff and children files reviewed. LPA obtained personnel report and children record. Based on the information that were gathered through interviews with staff and other, the facility had been providing ongoing to support to staff and children regarding care and supervision. Parent was notified in the timely manner. According to the available information, it does not appear this incident was the result of the Title 22 violation for lack of care and supervision.

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, Joanna Williams.

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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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