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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601954
Report Date: 12/07/2022
Date Signed: 12/07/2022 09:39:58 AM


Document Has Been Signed on 12/07/2022 09:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:UCLA EARLY CARE AND EDUCATION-INFANTSFACILITY NUMBER:
191601954
ADMINISTRATOR:AMY AGNEWFACILITY TYPE:
830
ADDRESS:101 S. BELLAGIO DR.TELEPHONE:
3108255086
CITY:LOS ANGELESSTATE: CAZIP CODE:
90095
CAPACITY:60CENSUS: 21DATE:
12/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Amy Agnew, Director TIME COMPLETED:
09:45 AM
NARRATIVE
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On 12/07/2022, 08:05AM, Licensing Program Analyst (LPA) Denise Miranda
conducted an unannounced case management inspection to the facility to deliver the investigation findings of the incident that was self reported by the facility and occurred on 11/09/2022. LPA met with Amy Agnew, center director, and discussed the purpose of the visit.

LPA observed 21 infants being supervised by 14 staff.

According to the incident report received, on 11/09/2022, Staff#1 warmed a bottle of breast milk for child#1, a baby in the infant classroom. Staff#1 placed it on the meal cart and warmed a bottle of breast milk for Child#2 and one of our interns took the bottle from the warmer, wrapped it in a towel without looking at the name of the child, and started to feed child#1 with child#2 bottle. The purpose of the towel is because the bottle is wet. The two families involved were notified immediately.

LPA obtained a copy of Child Care Facility Roster, sign in and out dated 11/09/2022, Staff time card for the day when this incident happened, photos where facility save the bottles of milk. Lon 11/28/222 LPA reviewed the Staff file that were involved on this incident and child#1 & Child#2 file, and were found completed.
LPA conducted interviews with the staff, child’s parent. LPA was unable to interview child#1 and child#2 due their age.
At the time of the incident that occurred, teacher to child ratios were within compliance.
SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: UCLA EARLY CARE AND EDUCATION-INFANTS
FACILITY NUMBER: 191601954
VISIT DATE: 12/07/2022
NARRATIVE
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Facility will be cited for PERSONAL RIGHTS 101223(a)(2). See LIC 809D. A Type A citation is issued today, 12/07/2022. A plan of correction has already been put in place and is defined on the LIC 809-D.

Upon receipt of a Type A deficiency, licensee shall post the report for 30 days in addition to the Notice of Site Visit & provide copies of the licensing report to parents/guardians of children in care at the facility by the close of business the following day or the next day child returns to the facility. The same report must be provided to parents or guardians of children newly enrolled at the facility during the next 12 months & licensee will obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file.

An exit interview was conducted with Amy Agnew, Director. A copy of this report, appeal rights along with a Notice of Site Visit were issued. Director was made aware that all other Licensing reports must be made available to the public for 3 years.

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/07/2022 09:39 AM - 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: UCLA EARLY CARE AND EDUCATION-INFANTS
FACILITY NUMBER: 191601954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2022
Section Cited

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Personal Rights: Each child shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as
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evidenced by, on 11/09/2022, a Staff#1 warmed a bottle of breast milk for chil#1, a baby in the infant classroom. Staff#1 placed it on the meal cart and warmed a bottle of breast milk for Child#2 and one of our interns took the bottle from the warmer, wrapped it in a towel without looking at the name of the child, and started to feed child#1 with child#2 bottle.
This is an immediate health and safety risk to the children in care.
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immediately. A copy of the training and staff attendance was provided on 11/28/2022 to LPA Miranda. Director will submit to LPA no later than tomorrow copy of LIC9224 form sign by parent/guardian from all infants enrolled and place a copy it in each child’s file.

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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: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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