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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019207
Report Date: 02/25/2025
Date Signed: 02/25/2025 11:06:16 AM

Document Has Been Signed on 02/25/2025 11:06 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 CC RO, 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: 11CENSUS: 8DATE:
02/25/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Facility RepresentativeTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Saul Valenzuela conducted an unannounced Case Management inspection due to an incident that was reported to the Department on 2/12/2025. LPA met with Facility Representative.

On February 12th, 2025, an incident was self reported to the Department via FAX by the facility who reported that a child was hit on their forehead by another child's foot



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 Valenzuela conducted interviews with staff. Per staff, Child #1 was sitting on the floor and was hit on the forehead by Child's #2 foot. Child #1 was taken to the school nurses office where first aid was administered. Child was not taken to the doctor and returned with no restrictions.

LPA provided Monterey Park Regional Office Incident email to Facility Representative.

At this time, 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.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Saul Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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