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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502478
Report Date: 02/04/2022
Date Signed: 02/04/2022 03:34:38 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:ST JAMES PARISH SCHOOLFACILITY NUMBER:
191502478
ADMINISTRATOR:KIM GOODRICHFACILITY TYPE:
850
ADDRESS:1325 MONTEREY ROADTELEPHONE:
(626) 799-6906
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY:90CENSUS: 0DATE:
02/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Bonnie Billmeyer, Pre-K TeachersTIME COMPLETED:
03:45 PM
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LPA Bardo Baluyot arrived to conduct a case management inspection to follow up on an incident reported to CCLD on 1/19/2022 where a child fell back while on the swings and injured her left arm. Teacher noticed a bulge at the elbow area and provided first aid and applied an ice pack. Parent was called immediately and arrived a short time later to take child to the ER. Parent informed school that arm was fractured and will have to wear a cast for two weeks and will update facility. LPA met with Pre-K Teacher Bonnie Billmeyer who guided LPA on a tour of the outdoor area and swing set. Swings were wrapped up and made inaccessible by maintenance staff by order of Reverend Anne. Per Ms. Billmeyer, swing will remain inaccessible until resolved with Licensing. LPA will conduct interviews with teachers present/ witness to the incident as Ms. Billmeyer was not present during the actual incident. Director Assadvazadorian nor any other staff or children were present at this time.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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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