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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192006215
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:52:44 AM

Document Has Been Signed on 06/23/2022 11:52 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:CHILD LANEFACILITY NUMBER:
192006215
ADMINISTRATOR:GABRIELA ACOSTAFACILITY TYPE:
850
ADDRESS:909 WEST D STREETTELEPHONE:
(562) 427-8834
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 15DATE:
06/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jackelina Velasquez, DirectorTIME COMPLETED:
11:55 AM
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On 06/23/2022 @ 9:45 AM, Licensing Program Analyst (LPA) Miriam Cohen conducted a Case Management Unusual Incident inspection to follow up on the self reported incident that occurred on 04/07/2022 at Child Lane Development Center, New Harbor Vista located at 909 “D” Street, Wilmington, CA 90744. The El Segundo Regional Office received the incident report on 04/07/2022. Upon arrival, LPA observed proper care and supervision. All center staff that was present during today’s inspection had fingerprint cleared and associated to the designated license number.
Based on the information that were gathered through record reviews, it revealed that there were three adults supervising children in the preschool program on the day of the incident. Per Site Supervisor (SS), Gaby Acosta (last day at Child Lane was on May 31, 2022), as documented in the UIR form LIC 624, she witnessed the incident and cared for child #1 (C1) after the incident. Two other staff members were also present but did not witness the incident.
Based on SS narrative, C1 was building a “bridge” along with other children during morning playtime. C1 decided to step on the bridge, and it tipped over causing him to lose balance. C1 fell forward and hit his right brow on the edge of the sensory table leg. Ms. Acosta immediately provided care for C1 with TLC, paper towels to stop the bleeding, and ice pack to reduce inflammation. Parent was notified immediately, and father came to pick up C1. Ms. Acosta encouraged father to take C1 to the doctor for treatment and observation. C1 was diagnosed with laceration on the right eyebrow. Instructions from the physician included leave bandage for six days, keep it dry, and return to Emergency Room if worsening pain, redness, or concern. C1 was released from medical care on 04/07/22 and returned back to preschool on 04/11/2022.

At this time based on the available information, it does not appear this incident was the result of a Title 22 violation for lack of care and supervision. The content of this report was read and discussed in detail with Jackelina Velasquez, preschool director. An exit interview was conducted; the notice of site visit must be posted for 30 days upon receipt.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Miriam Cohen
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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