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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019203
Report Date: 11/10/2021
Date Signed: 11/10/2021 01:29:00 PM

Document Has Been Signed on 11/10/2021 01:29 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:ROOSEVELT HEAD STARTFACILITY NUMBER:
198019203
ADMINISTRATOR:LA TUNYA FISHERFACILITY TYPE:
850
ADDRESS:1574 LINDEN AVETELEPHONE:
(562) 218-1164
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY: 24TOTAL ENROLLED CHILDREN: 19CENSUS: 7DATE:
11/10/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Patricia Lopez & Jenny AcostaTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Rita Ramos conducted an unannounced collateral visit to the above facility on 11/10/21. LPA arrived at 12:25PM and met with Patricia Lopez, Head Teacher who provided a tour of the facility. There were 14 children and 4 staff present upon arrival. LPA was later met by Jenny Acosta, Program Administrator for Support Services.

The purpose of the visit was to interview Staff #4 for an incident that pertains to another licensed facility (#198020043) in which Staff #4 was present on or before the incident prior to transferring to Roosevelt Head Start.

During the visit LPA interviewed Staff #4.

There were no deficiencies cited during the visit.

Exit interview was conducted with Jenny Acosta, Program Administrator of Support Services. .

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Rita Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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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