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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015475
Report Date: 05/06/2024
Date Signed: 05/06/2024 02:38:57 PM

Document Has Been Signed on 05/06/2024 02:38 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:JOHN W. MACK CENTER, USC HEAD STARTFACILITY NUMBER:
198015475
ADMINISTRATOR/
DIRECTOR:		DEBBIE GIPSONFACILITY TYPE:
850
ADDRESS:3020 SOUTH CATALINA STREETTELEPHONE:
(213) 743-4651
CITY:LOS ANGELESSTATE: CAZIP CODE:
90007
CAPACITY: 45TOTAL ENROLLED CHILDREN: 29CENSUS: 24DATE:
05/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Kenicia MotaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) T. Tran conducted an unannounced Case Management Incident visit at the above licensed facility to follow up self-reported incident occurred on 04/26/2024. The Monterey Park Southwest Office received the written report on 04/26/2024. Upon arrival, LPA met with Site Supervisor, Kenicia Mota and we toured the facility. LPA observed children were napping, no concerns with the level of care and supervision.

LPA completed child and staff’s files review. LPA obtained child's document and personnel report.
Interviews were conducted with staff and other. Record review indicated, on the day of the incident, there were 11 children with three teachers. Parent was notified immediately after the incident. Per parent, the injury does not require medical care. Child still enrolling in the program and attending school regularly. There were no changes in the behavior. Based on the available information it does not appear this incident was the result of a 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, Kenicia Mota.

SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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