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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020337
Report Date: 03/03/2023
Date Signed: 03/03/2023 01:19:26 PM

Document Has Been Signed on 03/03/2023 01:19 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:SEGRAY EAGLE ROCKFACILITY NUMBER:
198020337
ADMINISTRATOR:STEVE HELLERFACILITY TYPE:
850
ADDRESS:4475 EAGLE ROCK BLVD.TELEPHONE:
(323) 507-2640
CITY:LOS ANGELESSTATE: CAZIP CODE:
90041
CAPACITY: 155TOTAL ENROLLED CHILDREN: 155CENSUS: 62DATE:
03/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Director Jennifer Lemay LandaTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Veronica Martinez Garza conducted an unannounced Case Management inspection at the above facility. A COVID-19 risk assessment was conducted prior to entering the facility. LPA wore appropriate personal protective equipment. The purpose of this inspection is to follow up on an unusual incident report that occurred on 02/28/23. The facility reported this incident to the Department within the required 24 hours. LPA met with Director, Jennifer Lemay Landa who guided LPA on a tour of the facility. Census was taken.

On 02/28/23 at approximately 09:30AM Child #1 (C1) and Child #2 (C2) were playing at the Mulberry Tree C2 pushed C1 off causing C1 to fall. C1 fell hitting his head sustaining a 1.5inch cut on the right side of his upper forehead. The facility provided first aid and called parents of C1. Parent #2 (P2) picked up C1 and took C1 to Urgent Care. C1 received 2 staples. C1 returned to the facility on 03/01/23.

During this inspection, LPA interviewed, Director, Staff #1-6, Child #1 and #2, and Parent #1. Director provided LPA with a copy of the children's roster. LPA was unable to complete interviews on this date. LPA needs to interview S#7 and Parent #2, a follow up visit will be required at a later date.



No citations have been issued at this time.

The Notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative, a civil penalty of $100 can be assessed.

Exit Interview was conducted and appeal rights were given, along with a copy of this report was provided to the Director, Jennifer Lemay Landa.
End of report
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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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