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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191226432
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:42:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2023 and conducted by Evaluator Anomeh Eivazian
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20230711145510
FACILITY NAME:SUSANNA WESLEY CHILDREN'S CTR/INFANTFACILITY NUMBER:
191226432
ADMINISTRATOR:MORENA DURANFACILITY TYPE:
830
ADDRESS:134 N. KENWOOD ST.TELEPHONE:
(818) 548-6229
CITY:GLENDALESTATE: CAZIP CODE:
91206
CAPACITY:19CENSUS: 9DATE:
07/20/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Morena Duran, DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Day care is out of ratio
Staff leave napping infants unattened
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced complaint inspection in regards to the above allegations. LPA arrived at 8:40 a.m. on 07/20/2023 and met with teacher, Manita Pascul and teacher assistant, Celia Nunez in the infant Red and Blue classrooms. Upon LPA's arrival to the facility director was not present in the facility. At 10:15 a.m., Morena Duran, director arrived to the facility who guided analyst on a tour of the facility. During this inspection there were 9 infants present in the facility, 6 infants in Red classroom and 3 infants in Blue classroom with 3 staff.

During this investigation, LPA Eivazian conducted interviews with six staff. LPA obtained a copy of sign in/out sheets for 07/20/23 and 07/10/23.

Based on an interview that was conducted with staff#3, on 07/10/23 there were total of 5 infants present in the Blue Infant classroom and staff#3 was supervising 5 infants alone on 07/10/23.
REPORT CONTINUES ON NEXT PAGE 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 33-CC-20230711145510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SUSANNA WESLEY CHILDREN'S CTR/INFANT
FACILITY NUMBER: 191226432
VISIT DATE: 07/20/2023
NARRATIVE
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Based on staff#1 and staff#4 interviews, on 07/20/23, staff#4 who is a teacher assistant opened the infant program and staff#4 supervised two infants alone from 7:30 AM to 8:30 AM until staff#2, fully qualified teacher arrived.

Based on interviews that were conducted with staff #2, staff#3, and staff#4, infants of Red room take nap in the crib room. Mostly a staff member is not present in the crib room while infants are napping, however staff supervise the napping infants in the crib room through the glass walls and baby monitor and try to check on napping infants every 15-20 minutes. Per staff#3 and staff#4 there were occasions that they were busy and were not able to check on napping infants in person in the crib room every 15 minutes.

Based on LPA Eivazian observations on 07/20/23, at 9:45 AM, staff#4 put an infant to sleep in the crib room and did not check on the infant in person until 10:10 AM.

Based on staff interviews, the facility was not in compliance with the staff-infant ratios requirement on 07/10/23 in Blue Infant Room and on 07/20/23 from 7:30 AM to 8:30 AM in Infant Red and Blue Rooms.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been meet, therefore the above allegation is found to be Substantiated at this time. California Code of Regulations, 101416.5 (b)--Staff-Infant Ratio: There shall be a ratio of one teacher for every four infants in attendance is being cited on the attached LIC9099D.

LPA Anomeh Eivazian informed director, Morena Duran that this report dated 07/20/2023 document(s) 1 of Type A citation. Type A citation which shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Anomeh Eivazian informed the director, Morena Duran to provide a copy of this licensing report dated 03/01/2023 that documents 1 Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the director, Morena Duran at 2:00 PM..


REPORT END 2 of 2
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 33-CC-20230711145510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: SUSANNA WESLEY CHILDREN'S CTR/INFANT
FACILITY NUMBER: 191226432
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2023
Section Cited
CCR
101416.5(b)
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Staff-Infant Ratio: There shall be a ratio of one teacher for every four infants in attendance.
This requirement was not met as evidenced by...
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Per director, she will have an additional teacher in infant room effective 07/21/23. A written plan will be submitted to LPA via email.
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Based on staff#1 and staff#4 interviews, on 07/20/23 from 7:30 AM to 8:30 AM , staff#4, teacher assistant supervised 2 infants alone. Per staff#3, on 07/10/23, she supervised 5 infants alone. This poses an immediate health, safety and personal right risk to the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 33-CC-20230711145510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: SUSANNA WESLEY CHILDREN'S CTR/INFANT
FACILITY NUMBER: 191226432
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
101429(a)(1)
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Responsibility for Providing Care and Supervision for Infants
Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times.
This requirement was not met as evidenced by...
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Per director, a meeting will be held with staff to review safe sleep and napping infants supervision.

LPA provided a copy of Infant Nap Chart to director during this inspection.
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Based on LPA Eivazian observation, on 07/20/23 an infant was napping in the crib room from 9:45 AM to 10:10 AM with door closed, none of the staff check on the napping infant in person in the crib room. This poses a potential health, safety and personal right risk to the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4