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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750009
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:20:24 PM

Document Has Been Signed on 12/17/2021 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:BARSTOW HEAD START/STATE PRESCHOOLFACILITY NUMBER:
367750009
ADMINISTRATOR:PAMELA MCQUAINFACILITY TYPE:
850
ADDRESS:1121 W MAIN STREETTELEPHONE:
(888) 543-7025
CITY:BARSTOWSTATE: CAZIP CODE:
92311
CAPACITY: 66TOTAL ENROLLED CHILDREN: 66CENSUS: 8DATE:
12/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:CHARLENE SAAVEDRATIME COMPLETED:
02:35 PM
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On 12/17/2021 Licensing Program Analyst LPA Babatunde Ibitoye
conducted a Case management incident inspection to follow up on an Unusual Incident
reported to the department on 12/14/2021. LPA spoke with Clerk Sec Charlene Saavedra, A tour of the facility was conducted with Sub Teacher Aide NIKKI McQueen .
Description of the incident: On 12/13/2021 at about 10:43AM Child #1 was walking on the play ground and child #2 ran into her causing child #1 to fall on both hands onto the rubber surface.Staff applied ice pack and the parent called and notified the facility that child was diagnosed with fractured on the left hand . The purpose of the inspection is to conduct interview with staff that witnesses the incident. Present during the time of this inspection and providing care is , 3 Teachers with the 8 children.The copy of facility roster for the incident day was collected.
Further investigation is needed, An exit interview was conducted, and a copy of this report was read and provided to Clerk Sec Charlene Saavedra along with Notice of Site Visit.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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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