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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500168
Report Date: 11/18/2021
Date Signed: 11/18/2021 09:48:22 AM

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:MAGNOLIAFACILITY NUMBER:
191500168
ADMINISTRATOR:CARMEN SANTANAFACILITY TYPE:
850
ADDRESS:11700 PILGRIM WAYTELEPHONE:
(562) 699-1500
CITY:WHITTIERSTATE: CAZIP CODE:
90601
CAPACITY:40CENSUS: 27DATE:
11/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Alma Larios TIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Judy Mora conducted a case management inspection due to an incident that occurred on 11/05/21. LPA met Lead Teacher Alma Larios. LPA toured facility independently at approximately 9:15 AM.

LPA observed 15 children with 02 staff in Room 1 and 12 children with 02 staff in Room 2.

The incident that occurred on 11/05/21 was reported to the Department on 11/05/21. The incident was reported in a timely manner. The incident which occurred on 11/05/21 consisted of a child who was injured and medical attention was required.

During this inspection LPA obtained a copy of the facility's supplemental incident report, Individualized health care plan and note from doctor to return to school. The child who was injured and the staff that was present at the time of the injury were not present during this inspection.

LPA visually observed the apparatus where the incident occurred. Facility equipment was observed to be age appropriate and safe. LPA also observed the area under the structure to have cushioned material.

A follow up inspection will be conducted to interview the staff who was present.

There were no deficiencies observed during today's inspection.

A Notice of Site Visit was given and must remain posted. Exit interview was conducted with Yadira Lugo, Education Coordinator. Appeal rights explained & provided.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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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