Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153808357
Report Date: 04/21/2016
Date Signed: 04/21/2016 01:59:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
FACILITY NAME:HEIR FORCE ACADEMYFACILITY NUMBER:
153808357
ADMINISTRATOR:RASH, BILLY J.FACILITY TYPE:
850
ADDRESS:4755 GOSFORD ROADTELEPHONE:
(661) 664-1066
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:75CENSUS: 29DATE:
04/21/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jennifer CoburnTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Brannon conducted a case management visit. LPA received an unusual incident report. The unusual incident occurred on 4/12/16. LPA interviewed staff, and reviewed staff and children's files.

Child #1 threw up a nickel sized blood clot. Staff immediately notified child's mother, and 911 was called. Mother arrived at center while EMTs were on site. Child was transported to local hospital, and then seen in a hospital in Los Angeles. Per staff, child #1 was discharged, and return to facility. Per interviews and documentation, facility acted in an adequate manner.

Per California Code of Regulations Title 22, Division 12, no deficiency cited during today's visit. Exit interview conducted with the director, Jennifer Coburn.

A COPY OF THIS REPORT MUST REMAIN IN THE FACILITY FOR PUBLIC REVIEW.
NOTICE OF SITE VISIT FORM POSTED TO PARENT'S BOARD.

To order forms, etc. visit our website at www.ccld.ca.gov
SUPERVISOR'S NAME: Rebecca VarelaTELEPHONE: (559) 243-8106
LICENSING EVALUATOR NAME: Cynthia BrannonTELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2016
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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