191504181-10-14-2021-33-CC-BBEL-C7SPPY-20211014113018

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191504181
Report Date: 10/14/2021
Date Signed: 10/14/2021 11:30:34 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:	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: 18	DATE:	10/14/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Director Liz Tomashefsky		TIME COMPLETED:	11:30 AM

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, follow-up Case Management-Incident inspection was conducted on this date by Licensing Program Analyst (LPA) Emiko Bell in order to provide the findings of the investigation into 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. Throughout the entire inspection, LPA and all children and staff wore face coverings as a precautionary measure against COVID-19. Upon LPA's arrival at the Preschool office, 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 09:35. In the Lavender room, there was one teacher and one parent volunteer with eight children; in the Sunflower room, there was one staff and were two parent volunteers with ten children. Staff-child ratio was met. All staff are cleared and associated. Throughout the course of the investigation, interviews were conducted with three staff, two parents, and one child; and 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 (C1) 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: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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: 10/14/2021

NARRATIVE

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The Unusual Incident which occurred is that on 09/21/21, sometime between 09:30-09:45 am, C1 was washing paint off of their hands at the outdoor sink located on the Lavender Room playground, and either slipped or took a misstep and fell off of the step stool; it was later determined that C1 sustained a fractured elbow.

On 09/21/21, the step stool was a one-step wooden stool about one foot high. There was no cushioning between the stool and the cement ground. According to Parent #1 (P1), they were with C1 while C1 was at the sink. P1 stated they had turned to get a napkin/paper towel for C1 to dry their hands and that was when C1 had slipped/took a misstep off of the stool.

According to Parent #2 (P2), they feel it was more the way C1 fell as opposed to the actual fall itself which caused C1 to sustain the fractured elbow--that when C1 descended, they possibly didn’t put their foot down straight.

Staff #2 (S2), who witnessed the incident, stated that they don’t recall seeing P1 with C1 at the sink, but corroborates that they don’t know if it was the way that C1 stepped off of the step stool or whether it was the balance between C1 and the stool, but the step stool flipped over, which may have caused C1 to then fall.

When C1 fell, they landed on their left elbow and back in between the legs of the step stool. C1 was crying and when asked where it hurt, indicated their left elbow and back. Staff #1 (S1) applied an ice pack to C1’s elbow and took a photo of the scrape on C1’s back before completing an incident report and reporting the incident to P2 via the Brightwheel app.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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: 10/14/2021

NARRATIVE

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It was on 09/22/21 that P2 took C1 to the doctor after noticing that C1 was “protecting” their arm and was unable to extend it; C1 was then diagnosed with a fractured elbow and their elbow was put in a soft cast for five days before being put in a hard cast. C1 is still in the hard cast.

By all accounts, this was an accident. The classroom was in ratio when the incident occurred (there was one staff, one parent volunteer and seven children present). After the incident, S1 immediately rendered aid to C1 and the one-step stool was replaced with a two-step stool. On 09/23/21, foam cushioning mats were ordered and on 09/28/21, the foam cushioning was placed under and around the step stool to provide cushioning in case another child falls.

It is unclear whether there was supervision since there is a discrepancy between P1 stating they were right next to C1 and S2 stating that they observed C1 alone at the sink. S1 states that they are trying to encourage the children to be more independent, and will thus permit them to do things alone, such as going to the sink to wash their hands. By Staff #3’s own admission, in order for a child to reach the outdoor sink, a step stool is required. C1 sustained a broken elbow by misstepping/slipping off of a one-step stool which is approximately one foot off of the ground. Though the Center has placed foam cushioning around the step and replaced the step stool with a higher, two-step stool, at the time of the incident, these precautionary measures were not in place on 09/21/21 when C1 slipped/misstepped off of the step stool. Thus, in order to further prevent another child from sustaining a broken bone, the Center is being cited for unsafe buildings and grounds (i.e. equipment).

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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: 10/14/2021

NARRATIVE

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Upon receipt, Director Liz Tomashefsky shall post the Notice of Site Visit and the deficiencies page of the report. This page and 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. A copy of this report shall be provided to the parents/guardians of the children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parents/guardians of any children newly enrolled at the facility for the next 12 months. The LIC 9224 Acknowledgement of Receipt of Licensing Reports must be maintained in each child's file immediately upon receipt from the parent. LPA provided Director Tomashefsky with a blank copy of the LIC 9224 Acknowledgement of Receipt of Licensing Report.

An exit interview was conducted with, and a copy of the report has been signed by and provided to Director Tomashefsky. Appeal Rights have been provided and explained to Director Tomashefsky as well.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/15/2021 Section Cited	1 2 3 4 5 6 7	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 is not met as evidenced by: On 09/21/21, C1 misstepped/slipped off of a
	8 9 10 11 12 13 14	one-step step stool, causing the stool to flip over, and C1 fell in between the legs of the stool and onto hard cement, sustaining a broken elbow. This poses an immediate risk to the health and safety of the children in care.	8 9 10 11 12 13 14	progress of the proposal.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC809 (FAS) - (06/04)

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