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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017157
Report Date: 08/23/2021
Date Signed: 08/23/2021 01:14:49 PM

Document Has Been Signed on 08/23/2021 01:14 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:HARRIETTE EVANS SHIELDS CDC/DREW CHILD DEVELOPMENTFACILITY NUMBER:
198017157
ADMINISTRATOR:SHIVERS, EDWINAFACILITY TYPE:
850
ADDRESS:224 E. 126TH STREETTELEPHONE:
(323) 779-6196
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 49TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
08/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Edwina Shivers - Site Supervisor TIME COMPLETED:
12:09 PM
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An unannounced Case Management Inspection was conducted on this day by Licensing Program Analyst (LPA) Alicia Bailey to address an Unusual Incident Report that was received in the licensing office on 08/20/2021. LPA met with Site Supervisor Edwina Shivers at 9:18 am who provided LPA a tour of the facility.

Child # 1 was playing in the wood chips and staff # 1 notice child # 1 crying. Staff # 1 dusted wood chips off and wash child # 1 face. Staff # 1 check child # 1 for any visible scratches or marks there were none visible. Child # 1 was hold Staff # 1 hands and begin crying again. Staff # 1 told child # 1 would call mom and continue to comfort child #1. Mother pick child #1 up at 4:35pm. The next day 08/20/21 at 9:45 am parent of child # 1 called asking to speak to child # 1 teacher. The teacher and parent had conversation , the parent wanted to know what happen to child # 1 the prior day. Parent stated child does not want parent to touch her arm. Parent took child #1 to doctor child has hairline fracture in the child arm.



Based on all information obtained on this date, and interviews conducted with Site Supervisor , no follow-up is necessary regarding the incident. The incident appears to be an accident . It appears to be nothing the Site Supervisor and the facility staff could have done to prevent the incident from occurring. The facility followed all proper procedures per the parent hand book/admission agreement, incident reports were sent in properly and timely, all medical needs were met if needed and parents notified.
There were no deficiencies observed in regards to today's visit.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Alicia Bailey
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: HARRIETTE EVANS SHIELDS CDC/DREW CHILD DEVELOPMENT
FACILITY NUMBER: 198017157
VISIT DATE: 08/23/2021
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There were no deficiencies cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1

Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty.

Exit interview, copy of report was given. Appeal rights were issued and discussed.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Alicia Bailey
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
LIC809 (FAS) - (06/04)
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