191227188-12-20-2022-33-CC-NTCG-CMAQBP-20221220110151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191227188
Report Date: 12/20/2022
Date Signed: 12/20/2022 11:02:01 AM

Document Has Been Signed on 12/20/2022 11:02 AM - 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:	MADISON PRESCHOOL		FACILITY NUMBER:	191227188
ADMINISTRATOR:	PATRICIA GUZMAN		FACILITY TYPE:	850
ADDRESS:	750 N. LOS ROBLES		TELEPHONE:	(626) 793-1181
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	22	CENSUS: 13	DATE:	12/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cinthia Martinez - Lead Teacher		TIME COMPLETED:	11:12 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced random annual inspection. Upon arrival at 9am, LPA met with Lead Teacher Cinthia Martinez. At 9:10am, LPA was led on a tour of the facility. This is a Preschool program which consists of 1 classroom. The classroom is a separate building on the campus of Madison Elementary School and is a part of the Pasadena Unified School District. Per licensee, there are currently 34 children enrolled in the program. This is a half day program with Hours of operation for this facility being Monday to Friday 7:45-10:45am for morning sessions, and 11:45am-2:45pm for afternoon session.

Licensing staff observed all required forms/publications to be posted outside the classroom door. Snack menus were reviewed to ensure that they are being posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request.

PHYSICAL PLANT: At 9:10am, LPA inspected the Preschool Room: 13 children with 2 staff members. Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children in a cabinet above the classroom counter/sink. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts. All floors are clean and safe. This facility does not have nap time due to being a half day program. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids. The facility was observed to be free of flies, other insects and rodents. Sufficient individual storage space for children was observed and each child has a cubby. Drinking water was readily available indoors through the drinking fountain. At this time, the elementary school Nurse's Office is used as an isolation area. A bed is available for an ill child to rest on. First Aid supplies are available and complete. Facility has a functioning carbon monoxide detector that meets statutory requirements. Director states there are no weapons, firearms, or bodies of water on the premises. REPORT CONTINUES PAGE 1 of 3

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: MADISON PRESCHOOL	FACILITY NUMBER: 191227188
	VISIT DATE: 12/20/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

At 9:20am, a fire extinguisher was observed. The valve on the required 2A 10BC fire extinguisher indicates fully charged. The Fire extinguisher is behind a locked emergency glass door but the service tag was turned backwards. LPA was unable to observe the service date. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. There is restroom inside the classroom that has two toilets and sink available for children in care to use. All toilets, hand washing, and bathing facilities are safe, sanitary and are operating properly. Food is provided from the kitchen of the elementary school. This facility provides breakfast for the morning session and lunch for the afternoon session.

OUTDOORS: At 9:30am, LPA reviewed the outdoor play area. Outdoor playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with material that absorbs a fall. There is one outside play space that is directly accessible from the classroom back door. There are swings, playhouses, grass, and age appropriate play equipment available. The play area is physically separated from the rest of the elementary school campus. Drinking water is readily available outdoors.

FACILITY RECORDS: Digital sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. Staff files were unable to be reviewed at the time of inspection. Per Lead Teacher, staff files and disaster drill logs are held at Cleveland Elementary School, where all licensed schools/facilities in the Pasadena Unified School District store their staff files. Lead Teacher provided their Pediatric CPR/First Aid that expires 03/2023. An inspection to review staff files at the Cleveland location will be conducted at a later date. A random sample of Children’s Records were reviewed to ensure that they are complete.

INCIDENTAL MEDICAL SERVICES:

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

REPORT CONTINUES PAGE 2 of 3

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: MADISON PRESCHOOL	FACILITY NUMBER: 191227188
	VISIT DATE: 12/20/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

LPA advised the licensee how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov. AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com/

At this time, the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today.

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.

Exit interview was conducted with Cinthia Martinez, Lead Teacher, at 10:50am. Copy of report provided.

END OF REPORT PAGE 3 of 3

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3