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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364820543
Report Date: 10/30/2024
Date Signed: 10/30/2024 12:37:52 PM

Document Has Been Signed on 10/30/2024 12:37 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:AVUSD SITTING BULL ELEMENTARY SCHOOLFACILITY NUMBER:
364820543
ADMINISTRATOR/
DIRECTOR:		MARLENE EMLAYFACILITY TYPE:
850
ADDRESS:19445 SITTING BULL ROADTELEPHONE:
(760) 240-5278
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 4DATE:
10/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Nadine Arvizu- Lead TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On October 30th 2024, Licensing Program Analyst (LPA) Braddock and Licensing Program Manager Lady King met with facility representative, Nadine Arvizu who granted access to the facility. The purpose of the inspection was to conduct an unannounced case management inspection for a UIR received at Palmdale RO on 10/24/24. LPA & LPM disclosed the purpose of the inspection to the facility representative. When LPA &LPM arrived at the facility there were 4 preschool children in care with 2 lead teachers, and 1 assistant teacher and one volunteer. The hours of operation for the program are 8:30 am to 11:30 am and 12:30pm to 3:30pm.

During the inspection LPA & LPM observed the playing structure and took pictures. LPA and LPM met with Assistant principle Mr. Kalinich who allowed LPA and LPM to view the video of the above incident.The child's injury was considered a accident because the child missed a step while climbing on the equipment and hit his head which caused a open cut on the right side of his forehead. The existing play structure is age appropriate.

Facility representative informed LPA and LPM that the school district placed the playing structure off limits as of 10/29/24 and plans to replace the play structure due to another child creating a hole in the equipment. Per Facility representative the playing structures will be deemed off limits until replaced and the yellow caution tape will remain on the equipment.
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SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Sherell Braddock
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: AVUSD SITTING BULL ELEMENTARY SCHOOL
FACILITY NUMBER: 364820543
VISIT DATE: 10/30/2024
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Based on LPA & LPM observations and interviews conducted, the facility took appropriate measures to ensure the health and safety of each child. Therefore, no deficiencies will be cited at this time.
A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the facility representative.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Sherell Braddock
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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