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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750001
Report Date: 08/27/2021
Date Signed: 08/27/2021 02:47:44 PM

Document Has Been Signed on 08/27/2021 02:47 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:OAK TREE LEARNING CENTERFACILITY NUMBER:
367750001
ADMINISTRATOR:CARTER, JENNIFERFACILITY TYPE:
850
ADDRESS:680 W 40TH STTELEPHONE:
(909) 882-6979
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY: 56TOTAL ENROLLED CHILDREN: 0CENSUS: 19DATE:
08/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Melissa DavisTIME COMPLETED:
03:02 PM
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Licensing Program Analysts (LPA's) Dorsey & Ibitoye spoke with director, Melissa Davis, for the purpose of conducting a follow-up on a Case Management Unusual Incident Report (UIR) from the facility. This UIR was received by Licensing on 06/23/2021.

Description of incident: On 06/22/21 when Child #1's mother dropped off Child #3 she advised Staff #1 that Child #1 would not be attending due to a doctor finding a "rock/pebble" in their ear on 06/21/2021. Per Child #1 the "rock/pebble was placed in their ear by Child #2. According to the incident report the incident had to of happened before 05/28/21 because that was the last time Child #2 was present.

During this investigation, LPA interviewed staff and was guided on a tour of the playground. Based on interviews with staff it is unknown if or when the the alleged incident at the facility occurred, due to the large time gap of the last time Child #2 was present (05/28/2021) and when the doctor found the rock in Child #1's ear (06/21/2021). According to the Director she spoke to Child #2 about the incident and they did not know what happened.



Notice of Site Visit shall be posted for 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 director Melissa Davis. The Notice of Site Visit and Appeal Rights were given.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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