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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191599976
Report Date: 03/30/2023
Date Signed: 03/30/2023 03:26:38 PM


Document Has Been Signed on 03/30/2023 03:26 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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:NIEMES HEADSTART/STATE PRESCHOOLFACILITY NUMBER:
191599976
ADMINISTRATOR:LIDA BELTROCCOFACILITY TYPE:
850
ADDRESS:16715 S JERSEY AVENUETELEPHONE:
(562) 229-7958
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY:40CENSUS: 28DATE:
03/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Laura HernandezTIME COMPLETED:
03:50 PM
NARRATIVE
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The Licensing Program Analyst (LPA), T. Tran, made an unannounced visit at Niemes Head Start to conduct a case management incident inspection that was self reported by the facility to the Child Care Licensing Department on 3/17/23 regards to lack of care and supervision. LPA met with Education Coach, Laura Hernandez and toured the facility inside and outside. LPA observed proper care and supervision.

LPA reviewed children’s files, obtained child's record, and other document. Staff records located at the main office not available at the site for review during today's visit. Interview was conducted with staff, children, and other.

Based on the facts presented and the information gathered during the interviews. On 3/17/23, there were 16 children with two staff. About 10:28AM, during the transition from outside to inside, as soon staff closes the classroom's door, staff heard a knock on the door then found C1. Child was left outside at the play area for about 5 seconds without any adult's supervision. In addition, facility failed to complete the 24 hours telephone report to the department for the above incident. According to the available information, this incident was the result of a Title 22 violation for lack of care and supervision and reporting requirement.

Facility will conduct a staff meeting/training to discuss proper care and supervision during transition time. The copy of agenda of the meeting/training and the list of attendee's with their signatures submit to CCLD by 04/14/2023 as a plan of correction. LPA discussed the regulations regarding reporting unusual incidents and injuries within 24 hours and sending the written incident report to the department within 7 days.

Type B deficiencies was cited at this time. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Laura Hernandez.

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/30/2023 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: NIEMES HEADSTART/STATE PRESCHOOL
FACILITY NUMBER: 191599976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited

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Care and Supervision. No child(ren) shall be left without the supervision, including visual observation. Staff failed to provide proper supervision while a child was left outside unsupervised.
This requirement is not met as evidenced by based on interviews staff failed to provide proper care and supervision for C1.
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Facility will conduct a staff meeting/training to discuss proper care and supervision during transition time. The copy of agenda of the meeting/training and the list of attendee's with their signatures submit to CCLD by 04/21/2023 as a plan of correction.
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On 3/17/23, about 10:28AM, C1 was left outside at the play yard area for about 5 seconds without any adult's supervision, which poses a potential health and safety risk to children in care.
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Type B
04/21/2023
Section Cited

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Reporting requirement
This requirement is not met as evidenced by based on record review facility failed to complete the 24 hours telephone report to the licensing department for the incident occurred on 3/17/23, which poses a potential health and safety risk to children in care.
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Facility representative will complete a declaration statement ackowledging the understanding of proper reporting requirement to the departement by 4/21/2023 in order to clear this citation.

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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: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2