Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403006
Report Date: 04/22/2016
Date Signed 04/22/2016 11:41:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME:OLMSTEAD FAMILY DAY CAREFACILITY NUMBER:
197403006
ADMINISTRATOR:OLMSTEAD, MAY A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 385-1147
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY:14CENSUS: 5DATE:
04/22/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:38 AM
MET WITH:May OlmsteadTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Myriam Saullo Luga conducted a visit to investigate the incident of a child falling and sustaining an injury. LPA met with the licensee and explained the purpose of the visit. Licensee reported the injury/sent the department the incident report within 24 hours of the incident's occurrence. LPA toured the facility indoor and outdoor including the location where the incident occurred. The area looked clean and orderly and was free of hazards. Staff were providing visual supervision to children during the visit. LPA interviewed licensee , licensee assistant , the child's parent and children. LPA reviewed the child's record.
Based on record's review, statements provided by children, parent and staff, and evaluation of the facility, this incident was determined to be a sole accident. No deficiency was noted.
An Exit interview was conducted and a copy of this report
SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (310) 337-4332
LICENSING EVALUATOR NAME: Myriam LugaTELEPHONE: (310) 337-4365
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2016
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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