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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153801052
Report Date: 09/18/2024
Date Signed: 09/18/2024 10:19:24 AM

Document Has Been Signed on 09/18/2024 10:19 AM - 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:CALIFORNIA CITY CHILD DEVELOPMENT CENTERFACILITY NUMBER:
153801052
ADMINISTRATOR/
DIRECTOR:		GONZALES, YOLANDAFACILITY TYPE:
850
ADDRESS:9124 CATALPA AVENUETELEPHONE:
(760) 373-7605
CITY:CALIFORNIA CITYSTATE: CAZIP CODE:
93505
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 13DATE:
09/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Anna NunezTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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On 9/18/2024, Licensing Program Analyst (LPA) Carol Heath met with the supervisor,Anna Nunez for a case management incident inspection involving a Unusual Incident Report (UIR) received by telephone on 9/16/2024. LPA toured the facility and took a census of the children. Upon arrival, 13 children, 2 staff, the site supervisor, and a Family service worker were present today.

Description of the incident: An incident occurred on 09/13/2024 at approximately 1:10 PM. PRO Officer of the Day (OD) received a telephone call from Program Manager Janey Felsoci to report that Child #1 pushed another child down the slide, causing the child to injure the right elbow. The parent took the child to the doctor the following days. Two teachers were present but did not witness the incident.
The facility failed to comply with care and supervision requirements, which mandate that teachers supervise children at all times. The LPA reviewed the facility roster, along with Child #1’s file and the doctor's report. The incident resulted in the child sustaining a nursemaid’s elbow.
Based on the information obtained, it has been determined that the facility failed to comply with Title 22 regulation 101229, which led to a childcare related injury on 9/13/2024. As a result, the facility is being cited for a Type B deficiency (See Facility Evaluation Report LIC 809D for deficiency).
An exit interview was conducted, and the report was reviewed with the supervisor, Anna Nunez.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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 09/18/2024 10:19 AM - It Cannot Be Edited


Created By: Carol Heath On 09/18/2024 at 09:47 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: CALIFORNIA CITY CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 153801052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision: 101229(a)(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement is not met, as evidence by:
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After the accident,the supervisor discussed the situation with the teaching staff, agreeing that students will go outside only when all three staff members are available. During the visit, the supervisor submitted her correction plan and agreed to follow it to ensure continuous supervision of the children.
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Based on interviews, the teachers did not supervise the children during outdoor playing and caused a child to injure the right elbow, which poses a potential risk to the health and safety of children 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:Carol Heath
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
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