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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501773
Report Date: 06/10/2022
Date Signed: 06/10/2022 01:50:19 PM


Document Has Been Signed on 06/10/2022 01:50 PM - 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:CLAREMONT UNITED METHODIST NURSERY SCHOOLFACILITY NUMBER:
191501773
ADMINISTRATOR:JERI BOLLMANFACILITY TYPE:
850
ADDRESS:211 W. FOOTHILL BLVD.TELEPHONE:
(909) 624-8223
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:75CENSUS: 26DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Jeri Bollman, DirectorTIME COMPLETED:
02:00 PM
NARRATIVE
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On 06/10/2022 at 10:23AM, Licensing Program Analysts (LPAs) Monique Ayala and Steven Tung conducted an unannounced required 1 year inspection. LPAs met with Director, who guided the LPAs on a tour of the facility. This is a preschool age program licensed for 75 children which operates Monday through Friday from 7:30AM to 4:30PM. Per the Director there are 80 children enrolled.

The following classrooms were inspected: yellow room: 6 children; purple room: 13 children; turquoise room: 7 children; blue room: 0 children. Teacher-child ratios were observed to be in accordance with Title 22 Regulations. Staff names were recorded. All children were observed to be under supervision, including visual supervision. Licensed facility is within the conditions, limitations, and capacity specified on the license.

The classroom furniture and equipment was inspected for good repair, free of sharp, loose, or pointed parts. All indoor classrooms were inspected to ensure that the floors have a surface that is safe and clean. All toilets and washing facilities are in safe and sanitary operating conditions. All materials and surfaces accessible to children are toxic free.

The facility does not provide any food for the children in care but does provide water. Parents provide all meals for children in care. Food is stored in day care children’s backpacks/lunch boxes.

LPAs observed that there are functioning smoke and carbon detectors in the facility. LPAs observed a fully charged and serviced fire extinguisher. Emergency disaster drill was last conducted on 04/26/2022.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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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: CLAREMONT UNITED METHODIST NURSERY SCHOOL
FACILITY NUMBER: 191501773
VISIT DATE: 06/10/2022
NARRATIVE
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Outdoor playground equipment is in safe condition, free of sharp, loose or pointed parts, with the exception of a canoe that was observed at 10:30AM having broken pieces leaving sharp edges.. 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 adequate shade in the play yard.

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. LPAs reviewed staff records, staff files were not complete and required licensing forms and training were missing (Mandated reporter, First Aid and CPR, Immunization records, Influenza, LIC198, LIC503 and LIC508).

Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. Criminal Records Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed.

SB792 (Immunization Requirements for Staff and Employees) was discussed with the Director. The Director and staff do currently have immunization documentation.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.


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

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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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: CLAREMONT UNITED METHODIST NURSERY SCHOOL
FACILITY NUMBER: 191501773
VISIT DATE: 06/10/2022
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(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

LPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.



Director 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.

Based on the LPA’s observations and records reviews, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, and a copy of the report was provided to director along with appeal rights.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/10/2022 01:50 PM - It Cannot Be Edited

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: CLAREMONT UNITED METHODIST NURSERY SCHOOL
FACILITY NUMBER: 191501773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239(n)
Fixtures, Furniture, Equipment and Supplies
(n) Furniture and equipment shall be maintained in good condition, free of sharp, loose or pointed parts.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, the canoe in the sand area was broken and chipped which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Director will talk with staff to place pool noodles on broken peices or remove the canoe entirely.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above 4 staff record views out of 6 staff record reviews were missing either immunizations and/or influenza which posesd a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Director will look for missing documents and/or ask staff to bring a copy of their records.

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: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 06/10/2022 01:50 PM - It Cannot Be Edited

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: CLAREMONT UNITED METHODIST NURSERY SCHOOL
FACILITY NUMBER: 191501773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above 5 staff members do not have a current mandated reporter training which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2022
Plan of Correction
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Director will have staff complete training by POC date.
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above 1 staff members do not have a health screening report signed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2022
Plan of Correction
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Director will provide copy by POC date.

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: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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