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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191602514
Report Date: 01/29/2024
Date Signed: 01/29/2024 04:17:54 PM


Document Has Been Signed on 01/29/2024 04:17 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
L.A. DAYCARE-NO.WEST, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:DER KINDER GARDEN INFANT CENTERFACILITY NUMBER:
191602514
ADMINISTRATOR:JAYASURIYA, TARISHAFACILITY TYPE:
830
ADDRESS:1843 10TH ST.TELEPHONE:
(310) 318-3838
CITY:MANHATTAN BEACHSTATE: CAZIP CODE:
90266
CAPACITY:30CENSUS: 14DATE:
01/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:TARISHA JAYASURIYA, DIRECTORTIME COMPLETED:
04:30 PM
NARRATIVE
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On 1/29/2024, Licensing Program Analyst (LPA) Loyce Phillips arrived at the facility for the purpose of conducting a case management- deficiencies visit. Upon arrival LPA met with Director, Tarisha Jayasuriya. LPA observed 6 infants with 3 staff members and 8 napping toddlers with 2 staff members.

Upon arrival and inspection of the infant and toddler rooms, LPA observed the following:

1 Infant sleeping on their stomach without an LIC 9227 Individual Infant Sleeping Plan on file.

There was no documentation of 15-minute infant sleep logs for infants or toddlers.

LPA reviewed and explained PIN 20-24-CCP, safe sleep log, LIC 9227 and FAQ regarding infant safe sleep with Director.

Deficiency is cited in accordance with Title 22 of the California Code of Regulations and/or Health & Safety Codes (809-D).

An exit interview was conducted, a copy of this report, appeals rights and a notice of site visit were discussed and provided to Director.

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (310) 740-3038
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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 01/29/2024 04:17 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
L.A. DAYCARE-NO.WEST, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: DER KINDER GARDEN INFANT CENTER
FACILITY NUMBER: 191602514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2024
Section Cited
CCR
101429(1)(2)(a)(b)

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(1) Each infant shall be constantly supervised and under direct visual observation...(2)Sleeping infant(s) shall be directly observed by sight and sound at all times....Staff shall physically check on sleeping infant(s) every 15 minutes and document the following....
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Director agreed to review CCR 101429 and Safe Sleep Log with staff. Staff will implement safe sleep logs as soon as possible and send proof of correction to LPA by POC date.
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This requirement was not met as evidenced based on LPA's record review. LPA asked to review sleeping logs and Director stated the did not have 15 minute logs. This poses a risk to children in care if not corrected.
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Type B
02/09/2024
Section Cited
CCR101430(A)(1)

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(A)Staff shall place infants up to 12 month of age on their backs for sleeping.
This requirement shall not apply if the infant has a written....(1)This requirement shall not apply if the infant has a written medical exemption from a licensed physician...
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Director will have Authorized Representative complete LIC 9227 for all infants with the ability to roll and place in infants file by POC date.
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This requirement was not met as evidenced based on LPA's record review. LPA did not observed LIC 9227 in infant file. This poses a risk to children in care if not corrected.
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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: Karren StarksTELEPHONE: (310) 740-3038
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2