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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191599892
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:15:18 PM

Document Has Been Signed on 10/16/2024 01:15 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:WING LANE ELEMENTARYFACILITY NUMBER:
191599892
ADMINISTRATOR/
DIRECTOR:
M. YOKOYAMA, R. KHANNAFACILITY TYPE:
850
ADDRESS:16605 WING LANETELEPHONE:
(626) 933-5937
CITY:VALINDASTATE: CAZIP CODE:
91744
CAPACITY: 24TOTAL ENROLLED CHILDREN: 19CENSUS: 16DATE:
10/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Monica JarvisTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On October 16, 2024, at 10:00 am Licensing Program Analysts (LPAs) Carolyn Tuba and Mariah Aguirre conducted a case management inspection due to an incident that was self-reported and submitted by the facility. The incident occurred on 10/10/2024 at approximately 9:30 am outside on the playground. Covid risk assessment was conducted. LPAs met with Manager, Monica Jarvis. LPAs observed and took a census of 16 children with 3 staff.

The incident was reported to the Department within the required 24 hours of occurrence. The incident consisted with a child tripping and bumping their mouth on the step of the play structure outside.

During this investigation, LPAs conducted interviews with Staff #1 (S1), Staff #2 (S2) and photos were taken of the play equipment to ensure the safety. LPAs did not observe any hazards on or around the play equipment. Child #1 (C1) was not available for interview. S1 and S2 stated that the child was running up the steps and tripped, causing C1 to fall and bump their two front teeth on the step of the play structure. According to staff no other children were playing around C1 when this occurred. First aid was provided with an ice pack and parent was called. Authorized emergency contact person picked up the child shortly after the incident.

According to the Manager, parent of C1’s sought dental care due to an injury, however the Manager stated that special food accommodations must be made before C1 can return to school due to injury of the child. The dental/medical report was given to the parent of C1 was not available. The Manager sent via email a copy of the parent incident report to LPA, C. Tuba. LPAs were provided a copy of the note to return to school from the dental office during this visit.

No citations have been issued at this time.
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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: WING LANE ELEMENTARY
FACILITY NUMBER: 191599892
VISIT DATE: 10/16/2024
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A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Manager, Monica Jarvis.
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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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