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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191597778
Report Date: 02/09/2022
Date Signed: 02/09/2022 10:55:47 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:OPTIONS-HEAD START-NORTHAMFACILITY NUMBER:
191597778
ADMINISTRATOR:PAT BRIZUELAFACILITY TYPE:
850
ADDRESS:423 SHIPMANTELEPHONE:
(626) 913-0317
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY:25CENSUS: 9DATE:
02/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Teacher, Lorena VarelaTIME COMPLETED:
11:00 AM
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An unannounced Case Management visit was conducted today by Licensing Program Analyst (LPA) Bardo Baluyot to conduct interviews regarding an Unusual Incident Report submitted on 2/8/22 that involved allegations of inappropriate contact involving two students on the alleged victim's first day on 1/24/22. LPA met with Teacher, Lorena Varela who guided the LPA on a tour of the facility and provided a statement regarding the incident. LPA took photos of the facility including the restrooms.

Upon LPA's arrival, there were 9 children on site. Census was taken at 9:35 am. There were 3 staff present.

Upon receipt, the Licensee shall post the Notice of Site Visit and the Licensing report. This report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100 civil penalty.

Exit interview was conducted with Teacher, Ms. Varela and a copy of the report was provided. Appeal Rights procedures also provided and explained.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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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