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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018055
Report Date: 04/06/2023
Date Signed: 04/06/2023 11:25:37 AM

Document Has Been Signed on 04/06/2023 11:25 AM - 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 S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CHILDRENS INSTITUTE/IMPERIAL COURTSFACILITY NUMBER:
198018055
ADMINISTRATOR:AKIDA CROSBYFACILITY TYPE:
850
ADDRESS:11425 GORMAN AVE.TELEPHONE:
(213) 385-5100
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY: 24TOTAL ENROLLED CHILDREN: 13CENSUS: 10DATE:
04/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Carmelita ShortsTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) T. Tran arrived at CII-Imperial Courts Head Start to conduct a Case Management Incident inspection that was self-reported on 03/13/2023 regarding a lack of care and supervision concerns. Upon arrival, LPA met with Site Supervisor, Carmelita Shorts and we toured the facility. LPA observed proper care and supervision and ratio.

LPA conducted the interview with children and staff. Based on the available information that was gathered through interviews and record reviewed. On the day of the incident, there were 9 children at the outdoor play area supervised by two fully qualified staff. Per S1, during outdoor play, C1 went under the play structure to hide from the peers. As child came out then hit the top of the head and sustained a small cut. Parent was contacted immediately. Child had seen by a physician and no stitches required. Child returned to school without any restrictions. At this time 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, Carmelita Shorts.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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