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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191597832
Report Date: 07/19/2019
Date Signed: 07/19/2019 12:11:21 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:MAOF CHILD CARE CENTER - DOWNEYFACILITY NUMBER:
191597832
ADMINISTRATOR:ARACELY GARCIAFACILITY TYPE:
850
ADDRESS:8100 TELEGRAPH ROADTELEPHONE:
(562) 806-5054
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY:80CENSUS: 27DATE:
07/19/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Site SupervisorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tiffanie Tran arrived at the above facility to conduct a Case Management Incident inspection to follow up on the self-reported incident that occurred at MAOF Child Care Center on 05/08/19. The facility made the 24 hours self-report on 05/21/19. The Monterey Park SW Regional Office received the writing incident report on 05/21/19. Upon arrival, LPA observed proper care and supervision. All center staff that was present during today’s inspection had fingerprint cleared and associated to the designated license number. Per staff stated, today's children early dismissal at 12:00PM due to staff training in the afternoon.
LPA completed child and staff’s records review. LPA obtained child's document, and personnel report.
Based on interviews conducted, it revealed that during morning outdoor play about 9:45 AM, teacher and children were engaged in a ball activity. While C1 attempted to kick a ball he slipped then fell backward hitting the back of his head on the concrete area. There was no other children involved. Staff assessed child and no signs of bump or bruises. However, due to the head injury staff contacted parent. Child was taken to the hospital by parent and nothing was found. At this time based on the available information it does not appear this incident was the result of a Title 22 violation for lack of care and supervision.
However, the facility had violated the reporting requirement for the above incident in a timely manner. Upon the occurrence of any incident during the operation hours, 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, a written report containing the information shall be submitted to the Department within seven days following the occurrence of such event. therefore, the facility had been cited for Type B deficiency. Please see LIC 809D.
The content of this report was read and discussed in detail at the time of with the noted contact person.
An exit interview was conducted; the notice of site visit must be posted for 30 days upon receipt.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: MAOF CHILD CARE CENTER - DOWNEY
FACILITY NUMBER: 191597832
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2019
Section Cited
CCR
101212(d)(1)(c)
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Based on record review and interview facility failed to report an incident that occurred on 05/08/2019 to the department until 05/21/2019 which could poses a potential risk to the Health and Safety of the children in care.
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Facility will submit a declaration statement of understanding the reporting requirements and will ensure unusual incidents are reported within 24 hours fax or phone and written report within 7 days.
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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: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
LIC809 (FAS) - (06/04)
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