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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750009
Report Date: 08/05/2022
Date Signed: 08/05/2022 01:32:44 PM

Document Has Been Signed on 08/05/2022 01:32 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:BARSTOW HEAD START/STATE PRESCHOOLFACILITY NUMBER:
367750009
ADMINISTRATOR:PAMELA MCQUAINFACILITY TYPE:
850
ADDRESS:1121 W MAIN STREETTELEPHONE:
(888) 543-7025
CITY:BARSTOWSTATE: CAZIP CODE:
92311
CAPACITY: 66TOTAL ENROLLED CHILDREN: 66CENSUS: 16DATE:
08/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Deborah HarrisTIME COMPLETED:
01:35 PM
NARRATIVE
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On 08/05/2022 Licensing Program Analyst LPA Babatunde Ibitoye

conducted a Case management incident inspection to follow up on an Unusual Incident

reported to the department on 06/16/2022. LPA spoke with Program generalist (Deborah Harris), Description of the incident: On 06/16/2022 at approximately 12:30 PM Staff #1 alleged that she observed, Staff #2 (through a door window) pushing a child #1 head down on the table and shouting at him to lay down.

Based on the information gathered from interviews with all parties involved. It was determined that C#1 personal rights were violated. Therefore, the facility is being cited for a personal Rights violation.

Deficiency Cited see LIC 809D

Exit interview was conducted, a copy of this report, appeal Rights, and Notice of site visit was provided to the program generalists (Deborah Harris).

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/05/2022 01:32 PM - It Cannot Be Edited


Created By: Babatunde Ibitoye On 08/05/2022 at 12:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: BARSTOW HEAD START/STATE PRESCHOOL
FACILITY NUMBER: 367750009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
Section Cited
CCR
08/09/2022

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Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning.
This requirement was not meet Based on interview and record review Staff #2 was observed pushing child # 1 head down on the table and shouting at Child # 1 to lay down. Which poses an immediate health, safety, or personal right risks to a person in care
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The Site supervisor will put in wriiten how to prevent reoccurrence.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claretta Yates
LICENSING EVALUATOR NAME:Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022


LIC809 (FAS) - (06/04)
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