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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019207
Report Date: 04/30/2024
Date Signed: 04/30/2024 01:17:59 PM

Document Has Been Signed on 04/30/2024 01:17 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:BUSHNELL WAY ELEMENTARYFACILITY NUMBER:
198019207
ADMINISTRATOR/
DIRECTOR:
LILIANA NARVAEZFACILITY TYPE:
850
ADDRESS:5507 BUSHNELL WAYTELEPHONE:
(323) 255-6511
CITY:LOS ANGELESSTATE: CAZIP CODE:
90042
CAPACITY: 20TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
04/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Lead Teacher Stacey CardonaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Roxana Lopez conducted an unannounced Case Management inspection due to 1 incident that was reported to the Department on 3/14/2024. LPA met with Lead Teacher Stacey Cardona.

On March 14th, 2024, an incident was self reported to the Department via Email by the facility who reported that a child had hurt their ankle during care.



Incident was reported within the required 24 hours. The purpose of the inspection was to obtain additional information regarding the incident reported to the Department.

During the inspection, LPA Lopez conducted interviews with staff. Child tripped over a sand bag that was used to prevent flooding of yard. First aid was administered, child was not taken to the doctor and returned with no restrictions.

LPA provided a copy of regulation 101212 reporting requirements- and discussed incidents that should be reported.

For this inspection, the licensee is in compliance with California Code of Regulations Title 22. No deficiencies cited.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with facility representative, Liliana Narvaez.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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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