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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750001
Report Date: 06/14/2022
Date Signed: 06/14/2022 02:24:29 PM

Document Has Been Signed on 06/14/2022 02:24 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: 56CENSUS: 27DATE:
06/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH: Director, Melissa DavisTIME COMPLETED:
02:32 PM
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Licensing Program Analyst's (LPA) Maddox met with Director, Melissa Davis today for the purpose of conducting a Case Management inspection regarding an Unusual Incident that occurred on a June 10th, 2022.

Description of the incident: From interview with Director, on 06/10/22 around 11:00 am, child #1 was sitting on her knees while eating outside at the lunch table. Teacher had instructed child several times to sit down correctly at the table, child #1 didn't follow the instruction from the teacher, she continued to sit on her knees, lost her balance, and fell, hitting the back of her head. The teacher inspected child #1's head and did not notice a lump but still applied and ice pack to the area. After about an hour after child #1 hit her head, the children went down for nap for about an 1.5 hrs, the teacher checked her head again and noticed a lump. Director states when they noticed the lump, she called her Dad to inform him. Director states parents were notified through the Bright wheel app. and informed again when child #1 was picked up at the end of the day (at the normal pick-up time). No medical treatment was required. The ratio at the time of the incident was 1:12.

Based on information provided and interviews conducted the incident does not appear to have been the result of any violation of the Title 22 regulation. Exit interview conducted and a copy of report provided to Director, Melissa on this date. Copy of LIC 624 received during this inspection.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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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