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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017626
Report Date: 09/07/2022
Date Signed: 09/07/2022 03:23:21 PM

Document Has Been Signed on 09/07/2022 03:23 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:CII/MAIN STREET HEAD STARTFACILITY NUMBER:
198017626
ADMINISTRATOR:MELISA MORGANFACILITY TYPE:
850
ADDRESS:9505 SOUTH MAIN STREETTELEPHONE:
(213) 385-5100
CITY:LOS ANGELESSTATE: CAZIP CODE:
90003
CAPACITY: 90TOTAL ENROLLED CHILDREN: 83CENSUS: 71DATE:
09/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Tamara BeasleyTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) T. Tran conducted an unannounced Case Management Incident visit at CII/Main Head Start to follow up a self reported incident occurred on 08/15/2022 regards facility staff released a child to a person that was not listed on the emergency pick up list. The Monterey Park South West Office received the writing report on 08/17/2022. LPA met with Tamara Beasley, Site Supervisor.

LPA completed child and staff’s files review. LPA obtained child's document. Interviews were conducted with staff, child, and other. Based on the information that was gathered it is confirmed on 08/15/22, about 4:30PM, S1 released C1 to an unknown person that was not listed on the emergency pick up list. Based on the available information, staff failed to protect the health and safety of a child in care by releasing C1 to an unauthorized representative.

Per Site Supervisor, preventative measures was taking on 08/18/22, all center staff attended the training and reviewed topics of care and supervision and emergency pick up authorization. LPA obtained the training materials and staff attendance for the record.

Type B deficiency was cited and cleared 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, Tamara Beasley.

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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 09/07/2022 03:23 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 09/07/2022 at 01:23 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CII/MAIN STREET HEAD START
FACILITY NUMBER: 198017626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2022
Section Cited
CCR
1012239(a)(2)

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Personal Rights-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by based on interviews conducted, on 08/15/22, S1 failed to protect C1 personal rights by released child to an unknown
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Per Site Supervisor, preventative measures was taking on 08/18/22, all center staff attended the training and reviewed topics of care and supervision and emergency pick up authorization.
POC cleared during visit.
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person not listed on the emergency pick list.
which 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:Trevino Cochran
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022


LIC809 (FAS) - (06/04)
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