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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593623
Report Date: 05/09/2024
Date Signed: 05/09/2024 12:51:22 PM

Document Has Been Signed on 05/09/2024 12:51 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:MAXSON HEAD START/STATE PRESCHOOLFACILITY NUMBER:
191593623
ADMINISTRATOR/
DIRECTOR:
ALMA GONZALESFACILITY TYPE:
850
ADDRESS:12380 FELIPETELEPHONE:
(626) 652-4250
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 75TOTAL ENROLLED CHILDREN: 58CENSUS: 29DATE:
05/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Teacher Alma Sanchez TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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At 11:10 am Licensing Program Analyst (LPA) Roxana Lopez conducted an unannounced case management- incident inspection to the above facility. The purpose of this inspection was to follow-up on an incident that was self- reported to the department on 5/6/2024. LPA met with Teacher Alma who guided LPA a tour of the facility. Program facilitator Claudia Casillas arrived at 11:30am.

On 5/6/2024 an incident was self reported to the department. Per Incident reported, on 5/1/2024 Parent disclosed taking child # 1 to the dr- where it was determined that child had a fracture arm and arm was on a cast. Child # 1 fell at the facility on 4/29/24 and left home early. Incident was not reported within the required 24 hours of being notified of medical treatment and diagnosis. .

LPA conducted interviews regarding incident with staff and child. Both Staff # 1 and child disclosed that child was running around structure and tripped over a firefighter helmet that was located on the side of the structure, falling on arm. Per staff # 1 helmet was used by children playing under the structure. Incident was observed, ice was applied and parents were called. Child # 1 was out for a week after the incident, arm is in a cast for 4-6 weeks with restrictions. Per staff # 2 incident was reported within 24 hrs after the doctors note was submitted on 5/2/2024. LPA advised that incidents have to be reported 24 hrs from facility being aware of medical treatment and diagnosis.

At this time, the licensee is in compliance with California Code of Regulations Title 22. No deficiencies cited. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the facility representative Claudia Casillas. ----------- pg. 1 of 1 -----------
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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