191504181-9-28-2021-33-CC-BBEL-C7AR56-20210928124237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191504181
Report Date: 09/28/2021
Date Signed: 09/28/2021 12:42:44 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:	LA VERNE PARENT PARTICIPATION PRESCHOOL		FACILITY NUMBER:	191504181
ADMINISTRATOR:	GOMEZ, LISA		FACILITY TYPE:	850
ADDRESS:	909 EAST JUANITA AVE.		TELEPHONE:	(909) 599-9857
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	34	CENSUS: 12	DATE:	09/28/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Director Elizabeth Tomashefsky		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An unannounced in-person Case Management-Incident inspection was conducted on this date by Licensing Program Analyst (LPA) Emiko Bell to follow up on an Unusual Incident which occurred on 09/21/21 and was reported via phone on 09/22/21 and via email on 09/23/21 to Community Care Licensing (CCL). Throughout the entire inspection, LPA and all children and staff wore face coverings as a COVID-19 precautionary measure. Upon LPA's arrival at 09:25 am, LPA Bell was greeted by Director Elizabeth Tomashefsky, to whom the purpose of the inspection was announced. Director Tomashefsky guided LPA on a tour to take census at 09:37 am. In the Lavender room, there was one teacher and one parent volunteer with five children; in the Sunflower room, there were two staff and one parent volunteer with seven children. Staff-child ratio was met. All staff are cleared and associated. During today's inspection, interviews were conducted with two staff and one child. Throughout the course of the investigation, documentation in the form of the Incident Report from the Brightwheel app; the "Discharge Instructions" dated 09/22/21; the "After Visit Summary" dated 09/27/21 for Child #1 were obtained and photos of the outdoor sink and of the step stool were taken by LPA.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

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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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: LA VERNE PARENT PARTICIPATION PRESCHOOL	FACILITY NUMBER: 191504181
	VISIT DATE: 09/28/2021

NARRATIVE

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The Unusual Incident which occurred is that on 09/21/21, a Preschool child was washing their hands at the sink outdoors and slipped and fell off of the step stool.

Due to insufficient information available at this time, the above incident needs further investigation. The findings will be provided during the next inspection.

Upon receipt, Director Elizabeth Tomashefsky posted the Notice of Site Visit. The Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required will result in the issuance of a citation and the assessment of a $100 civil penalty.

An exit interview has been conducted with, and a copy of this report has been signed by and provided to Director Elizabeth Tomashefsky. Appeal Rights were provided and explained to same.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

LIC809 (FAS) - (06/04)

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