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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191231012
Report Date: 08/21/2019
Date Signed: 08/21/2019 01:21:23 PM

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:JACKSON PRESCHOOLFACILITY NUMBER:
191231012
ADMINISTRATOR:PATRICIA GUZMANFACILITY TYPE:
850
ADDRESS:593 W. WOODBURY ROAD #BTELEPHONE:
(818) 798-6773
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:24CENSUS: 21DATE:
08/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Ana PaikTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Ariel Cazares conducted an unannounced annual/random inspection on this date. LPA met with Teacher Ana Paik. Upon arrival LPA observed 21 children in care with 2 additional staff, a parent volunteer, and a student volunteer.

LPA inspected all areas used by the daycare children. The facility is located on the school campus of Jackson Elementary in Classroom #100. Access can be gained through the main entrance of the school during school hours. The facility operates an AM session from 7:45-10:45 and PM session from 11:45-2:45.

Furniture and equipment were inspected for age appropriateness and good repair. LPA observed age appropriate play equipment for children. Children have their own cubby to store their belongings. Children's restrooms are located in the classroom and were found to be clean and stocked with supplies for children to use.

Drinking water is available via a water fountain attached to a sink in the classroom. There are emergency supplies and first aid kit in the classroom. LPA observed a carbon monoxide detector in the classroom and tested it, finding it to be in operable condition. The facility provides one meal a day per session that is provided by the school's cafeteria.

The preschool has its own separate playground adjacent to the classroom. The outdoor equipment was inspected for safety, cushioning material, good repair and age appropriateness. Required shade and fencing were inspected. Outdoor drinking water is available via a water jug and cups.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Ariel AlmazanTELEPHONE: (323) 981-2949
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
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 2
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: JACKSON PRESCHOOL
FACILITY NUMBER: 191231012
VISIT DATE: 08/21/2019
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According to teacher, medication is stored in the nurses station on the school campus. Currently there are no children with medication needs. Ill isolation area is located in the cozy area in the classroom where a child can rest.

LPA reviewed children's files on site and found them to be complete. Staff files are kept off-site at the main office at 524 PALISADE ST., Pasadena CA 91103.



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

Exit interview conducted with Teacher Ana Paik. A copy of this report was provided.

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: Ariel AlmazanTELEPHONE: (323) 981-2949
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
LIC809 (FAS) - (06/04)
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