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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191598968
Report Date: 10/16/2023
Date Signed: 10/16/2023 04:45:28 PM


Document Has Been Signed on 10/16/2023 04:45 PM - It Cannot Be Edited

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:EL MONTE CITY SCHOOL DISTRICT - LE GOREFACILITY NUMBER:
191598968
ADMINISTRATOR:AUDELIA MACIASFACILITY TYPE:
850
ADDRESS:11121 E. BRYANT RD.TELEPHONE:
(818) 575-2393
CITY:EL MONTESTATE: CAZIP CODE:
91731
CAPACITY:84CENSUS: 0DATE:
10/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Lead Teacher, Silvia Brunswig TIME COMPLETED:
04:50 PM
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Licensing Program Analysts (LPAs) Roxana Lopez and Stacy Perry conducted an unannounced case management- incident inspection to the above facility. The purpose of this inspection was to follow-up on an incident that was self- reported to the department on 9/12/2023. LPA's met with Lead Teacher Silvia Brunswig, who guided analyst on a tour of the facility. Site Supervisor arrived at 4:40pm an took over the inspection.

On 9/15/2023 an incident was self reported to the department- report was not made within the required 24 hours. Per Site Supervisor Queta Morales, report was made when child came back with a doctor's note indicating child had a sprain. Per Incident reported Child # 1 was climbing up the structure when they lost balance and fell on their right arm. Ice pack was provided and parents were informed.

LPAs observed the structure and took pictures where incident happened. Staff was interview and documentation was reviewed. Staff disclosed that incident was observed, child was provided aid as soon as incident happened- Per staff child was taken to the doctor- doctor's note is on file child had restrictions unitl 10/14/2023.

At this time, the licensee is in compliance with California Code of Regulations Title 22. No deficiencies cited.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the facility representative Queta Morales. ----------------------- pg.1 of 1---------------------
SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Roxana LopezTELEPHONE: (323) 854-5073
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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