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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750009
Report Date: 03/08/2023
Date Signed: 03/08/2023 12:16:04 PM

Document Has Been Signed on 03/08/2023 12:16 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: 29DATE:
03/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Tawanda HenryTIME COMPLETED:
12:35 PM
NARRATIVE
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On March 8, 2023, Licensing Program Analyst (LPA) Babatunde Ibitoye made an unannounced visit for the purpose of delivering findings for the Unusual Incident received on 10/19/2022. LPA Met with Acting Site Supervisor Tawanda Henry. There are 29 day-care children present with 3 Teacher and 3 Teacher Aide .

The unusual incident report was regarding the parent of Child # 1 (Child in classroom 91), who Informed the supervisor Magdalene Arryayga, that C#1 Inserted a Piece of wiggly eyes inside her nose. On 10/11/22, Class 91 conducted a supervised activity in which they used wiggly eyes. On 10/12/22 night, the child informed her mother that her ‘’eye hurt but pointing at her nose

Based on the evidence obtained, it is determined Child # 1 personal rights were violated. This is corroborated by interviews, observations, and facility reports. Therefore, based on the evidence gathered. It is determined that a Personal Rights violation of the California Code of Regulations, Title 22, Division 12, Chapter 3, Sections 101223(a)2 occurred. Deficiencies are cited on LIC 809D

LPA informed the Acting site supervisor Tawanda Henry that this report dated (03/08/2023) documents Type A citation which shall be posted for 30 consecutive days as there is/are potential risk's to the health, safety, or personal rights of children in care.

Also, LPA informed the Acting Site Supervisor to provide a copy of this licensing report dated (03/08/2023) that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statements, must be placed in the child's file for verification.

An exit interview was conducted and the report was reviewed with the Acting Site supervisor Tawanda Henry. Site Visit and Appeal Rights were given

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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Document Has Been Signed on 03/08/2023 12:16 PM - It Cannot Be Edited


Created By: Babatunde Ibitoye On 03/08/2023 at 11:40 AM
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: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2023
Section Cited
CCR
101223(a)2

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 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment to meet his/her needs.
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1 . Per Acting site supervisor .The facility has stop using plastic wiggly eyes for activities and replace with Sticker wiggly eyes.

2 Per acting supervisor facility will maintain supervision with all children in care during and after activities.
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 Based on the interview and record review this requirement was not met as the Facility failed to ensure a safe, healthful, and comfortable accommodation and supervision during and after the class wiggly activity on 10/11/22 ,which resulted in C#1 Insert a piece of wiggly eyes Inside her nose . This poses Immediate health, safety, or personal rights risk to a person in care.

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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: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
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