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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191590008
Report Date: 09/22/2021
Date Signed: 09/22/2021 01:36:51 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:CHARTER OAK DAY SCHOOLFACILITY NUMBER:
191590008
ADMINISTRATOR:GOFRAN, ELANAFACILITY TYPE:
850
ADDRESS:20350 E. CIENEGA AVE.TELEPHONE:
(626) 967-6611
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:42CENSUS: 24DATE:
09/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Viviann Ivory, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA ) Thelma Razo and LPA Steven Tung held a Case Management - Deficiencies visit and met with Administrator Viviann Ivory. LPA Razo stated the purpose of the visit.

On 8/4/2021, Licensing received a phone call regarding a positive COVID-19 case for Staff #1 date of knowledge 7/30/2021. The incident was not reported within the required time frame as mandated per Title 22 Division 12 Chapter 1 Article 06. A deficiency was cited and is on LIC809-D.

The notice of site visit was posted where the parent/guardian of children enter and exit the facility. This notice shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

Exit interview conducted with staff, during which appeal rights were explained. A copy of the Appeal Rights (LIC9058) and this report were provided.

SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Thelma RazoTELEPHONE: (323) 981-3387
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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: CHARTER OAK DAY SCHOOL
FACILITY NUMBER: 191590008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2021
Section Cited

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Reporting Requirements
Upon the occurrence, during the operation of the child care center of any unusual incident that threatens the physical or emotional health or safety of any child, a report shall be made to the Department by telephone or fax within the Department's next working day and
during its normal business hours. In addition,
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a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. This requirement was not met as evidenced by daycare not reporting the incident that happened on 7/30/21 within next working day and was reported on 8/4/2021. This poses a potential health and safety risk to the children in care.
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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: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Thelma RazoTELEPHONE: (323) 981-3387
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021
LIC809 (FAS) - (06/04)
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