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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004480
Report Date: 09/08/2023
Date Signed: 09/08/2023 02:20:43 PM

Document Has Been Signed on 09/08/2023 02:20 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:HACIENDA LA PUENTE USD-BALDWINFACILITY NUMBER:
198004480
ADMINISTRATOR:INES ALBARRANFACILITY TYPE:
850
ADDRESS:1616 N. GRIFFITHSTELEPHONE:
(626) 933-3746
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 64TOTAL ENROLLED CHILDREN: 35CENSUS: 16DATE:
09/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ryan MartinezTIME COMPLETED:
02:25 PM
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On September 8, 2023, Licensing Program Analyst (LPA) Carolyn Tuba conducted a case management inspection due to an incident that occurred at the facility on 4/10/2023. LPA met with Site Supervisor, Ryan Martinez and took a census of 16 children with 2 staff. LPA was unable to conduct interviews with staff that witnessed the incident, as they are currently at other locations. The child who was injured and the other child involved have moved on to other schools. Per Site Supervisor they will send LPA via email the incident report given to parents.


The incident was reported to the Department within the required 24 hours of occurrence. The incident consisted with a child having an injury that required medical attention.

LPA was able to take photos. The incident occurred in the dramatic play area inside the HeadStart (HS3 classroom). Due to insufficient information available at this time, the incident needs further investigation.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Site Supervisor, Ryan Martinez.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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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