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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623991
Report Date: 05/11/2022
Date Signed: 05/11/2022 10:52:34 AM

Document Has Been Signed on 05/11/2022 10:52 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:SETA DUDLEY HEAD STARTFACILITY NUMBER:
343623991
ADMINISTRATOR:BHAVNEET KAURFACILITY TYPE:
850
ADDRESS:8000 AZTEC WAYTELEPHONE:
(916) 263-3737
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 13DATE:
05/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Bhavneet KaurTIME COMPLETED:
11:00 AM
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On 5/11/22 Licensing Program Analyst (LPA) Fabiola Diaz conducted a case-management inspection to follow-up on an unusual incident report (UIR) reported on 3/25/22 of an incident that occurred on 3/24/22. A written UIR was submitted to the Department within 7 days. LPA met with Site Supervisor Bhavneet Kaur, and LPA observed 13 children present with two additional staff.

On today's date LPA interviewed staff, reviewed Child 1's (C1) emergency information, and inspected the facility. Staff explained that C1 slipped on the first step of the play structure and hit the second step. Staff stated there were three staff supervising 20 children at the time of the incident. C1's parents were notified at the time of the incident. Further follow-up will be conducted by LPA and will remain in contact with Site Supervisor.

No deficiencies were cited on today's date. An exit interview was conducted with Site Supervisor, and a Notice of Site visit was provided. The Notice of Site Visit shall remain posted for 30 days.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Fabiola Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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