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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364820543
Report Date: 08/23/2022
Date Signed: 08/23/2022 02:09:49 PM

Document Has Been Signed on 08/23/2022 02:09 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:AVUSD SITTING BULL ELEMENTARY SCHOOLFACILITY NUMBER:
364820543
ADMINISTRATOR:MARLENE EMLAYFACILITY TYPE:
850
ADDRESS:19445 SITTING BULL ROADTELEPHONE:
(760) 240-5278
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 18DATE:
08/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:CARRIE MENDEZTIME COMPLETED:
02:27 PM
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On August 23, 2022 Licensing Program Analyst (LPA) Babatunde Ibitoye met with Teacher (Carrie Mendez)to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a self reported unusual incident report (UIR) submitted to the Department on August 5, 2022

Description of incident: On 08/05/22 Child #1 was climbing on the green climbing stairs on the north side of the preschool/kinder play structure, S#1 was about 8 feet away walking closer asking C#1 to come down off the structure. S#2 and S#3 was standing 10 ft away with visual. C#1 Crouched down at the top step with her hands holding the side rail. S#1 walked closer about 3 feet away,S#2 and S#3 started walking towards the play structure C#1 sat down on the top step and moved her hands closer to her body, she started to sway back and forth off balance and fell face forward hitting her lower lip on the structure and slipping through the space between the climbing stairs and the structure.

During this investigation, LPA interviewed staffs, and Child #1 parent. LPA was guided on a tour of the playground where the incident occurred. Based on interviews with staffs and Child #1 parent, LPA found according to interviews the facility was in ratio on the playground at the time of the incident and observed the swing area to be free of hazards to children's health or safety. Notice of Site Visit shall be posted for thirty (30) consecutive days. Failure to maintain posting as required will result in a $100 civil penalty.

An exit interview was conducted with and a copy of this report has been signed by and provided to Teacher ( Carrie Mendez), Site Visit and Appeal Rights were given.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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