Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191670506
Report Date: 06/22/2016
Date Signed 06/24/2016 07:36:38 AM

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:ARTESIA HIGH SCHOOL CHILDREN'S CENTERFACILITY NUMBER:
191670506
ADMINISTRATOR:ARLENE RIDDICKFACILITY TYPE:
850
ADDRESS:20651 NORWALK BLVDTELEPHONE:
(562) 229-7959
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY:104CENSUS: 12DATE:
06/22/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Arlene RiddickTIME COMPLETED:
09:25 AM
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LPA, S. Robinson-Horn conducted a Case Management visit to obtain additional information on an incident that occurred on 05.31.16. Upon arrival LPA met with Site Supervisor, Arlene Riddick and informed her of the nature of the visit.

Information reported to the Department indicated on 05.31.16 a child had a allergic reaction, facility was not aware as to what caused the allergic reaction. Facility does have a list of food items child is allergic to however none of those were given to child while at the facility.

During today’s visit interviews were conducted with staff and child file and LPA also obtained documents from child file.

Based on the information received during today’s visit the child had an allergic reaction while at the facility, what exactly caused the reaction is unknown. The child has several allergens and was not given any of the allergens listed.

The child was taken to his physician who could not identify what caused the reaction. The child was fine and returned to school the next day with a note from a physician. The parent of the child has not updated the facility of any new diagnosed allergens since the incident occurred.

There are no violations of Title 22 Regulations being cited at this time.

Web site address to order forms: www.ccld.ca.gov – To access licensing forms, updates and Title 22. Exit Interview completed with Site Supervisor,

The Notice of Site Visit (LIC 9213)must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Shameka Robinson-HornTELEPHONE: (323) 980-4930
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2016
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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