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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290371
Report Date: 09/22/2022
Date Signed: 10/06/2022 03:56:34 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
09/16/2022 and conducted by Evaluator Monique Jessica Ayala
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20220916135810
FACILITY NAME:JEFFERSON CHILDRENS CENTERFACILITY NUMBER:
191290371
ADMINISTRATOR:REE HUDSONFACILITY TYPE:
850
ADDRESS:391 NORTH SIERRA BONITATELEPHONE:
(626) 796-8845
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:70CENSUS: 26DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Carolina Arizaga, Facility SupervisorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Physical Plant: Facility gate is in disrepair.
INVESTIGATION FINDINGS:
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This is an Amended report to state that a COVID-19 risk assessment was conducted on this day and to indicate who LPA met with.

On September 22, 2022 at 11AM, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced complaint investigation for the above allegations. A COVID-19 risk assessment was conducted. LPA was greeted by teacher assistant, Ylda Mares who guided LPA on a tour of the facility. Faciity Supervisor, Carolina Arizaga arrived shortly after. LPA observed 26 children in care.

LPA observed the facility entrance gate to be propped open with a child stop sign toy. Upon LPAs arrival at 11AM. While assistant teacher was giving LPA a tour of the facility, LPA asked if the door was propped open for a reason? Per assistant teacher, she stated that someone must have left it propped open. Assistant teacher removed the child stop sign toy and the gate closed. LPA stepped out of the faciity and pressed the button where staff are able to open the gate from inside the facility; the door buzzed and LPA opened. While LPA was reentering the facility, LPA observed the gate not closing properly. LPA was able to push the gate open without pushing the push bar.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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 3
Control Number 33-CC-20220916135810
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: JEFFERSON CHILDRENS CENTER
FACILITY NUMBER: 191290371
VISIT DATE: 09/22/2022
NARRATIVE
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LPA again exited the gate and was able to pull the entrance gate open without needed to be buzzed in. Assistant teacher was also able to push the gate open and pull open the gate

Based upon the evidence as presented above, the allegation of the facility gate being in disrepair has been determined to be Substantiated. A finding of Substantiated means that the preponderance of evidence standard has been met. The facility is being cited a Type B deficiency, please see LIC9099D.

An exit interview was conducted and a copy of this report along with Notice of Site Visit and Appeal Rights were provided to facility supervisor, Carolina Arizaga.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 33-CC-20220916135810
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: JEFFERSON CHILDRENS CENTER
FACILITY NUMBER: 191290371
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited
CCR
101238(a)
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101238(a) Buildings and Grounds: The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement was not met as evidence by...Based on observation, the entrance gate was not closing properly
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Per supervisor, she will reach out to repair company to come inspect the door. Supervisor will keep LPA updated on repair of the gate.
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and was able to be opened without being buzzed in by staff. This poses a potienal health and sfaety risk to 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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3