Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197408577
Report Date: 04/10/2018
Date Signed: 04/10/2018 11:39:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME:SANTA MONICA-MALIBU USD/WASHINGTON WEST H.S./S.P.FACILITY NUMBER:
197408577
ADMINISTRATOR:ALICE CHUNGFACILITY TYPE:
850
ADDRESS:2802 4TH STREET, ROOM 2TELEPHONE:
(310) 399-5865
CITY:SANTA MONICASTATE: CAZIP CODE:
90405
CAPACITY:71CENSUS: 56DATE:
04/10/2018
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Johana Aviles, TeacherTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
The Licensing Program Analyst (LPA), Tiffanie Tran conducted a site inspection to deliver the final findings for an incident which occurred on 09/26/2017. LPA met with teacher Johana Aviles. LPA observed proper care and supervision. There were 4 staff supervising 13 children.

Based upon the available information through record review and interview conducted. it does not appear this incident was the result of a Title 22 violation.

The content of this report was read and discussed in detail at the time of with the noted contact person.

An exit interview was conducted; the notice of site visit must be posted for 30 days upon receipt.
SUPERVISOR'S NAME: Sharon GreeneTELEPHONE: (310) 337-4313
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: 310-337-4335
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2018
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 1