191670722-12-16-2021-54-CC-RRAS-C9S27Y-20211216160931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191670722
Report Date: 12/16/2021
Date Signed: 12/16/2021 04:09:39 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:	LBUSD-GRANT CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	191670722
ADMINISTRATOR:	KIMBERLY KELLY		FACILITY TYPE:	850
ADDRESS:	6405 WALNUT AVE		TELEPHONE:	(562) 422-4686
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90805
CAPACITY:	95	CENSUS: 16	DATE:	12/16/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Kimberly Kelly, Coordinating Teacher		TIME COMPLETED:	04:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) Rita Ramos conducted an unannounced case management inspection on 12/16/21. LPA arrived at the facility at 12:50 PM and was met by Kimberly Kelly, Coordinating Teacher, who guided analyst on a tour of the facility. There were 16 napping children present with 2 staff supervising upon arrival.

The purpose of the visit was to conduct a 2^nd follow-up on an incident that was reported to the department.

LPA Ramos conducted interviews and obtained documentation during this visit.

The incident that occurred on 11/15/21, was reported to the Department on 11/24/21, via fax. The facility did not report the Unusual Incident to the Department within the required 24 hours of occurrence. The facility was cited for not reporting within the required time on 12/09/21.

Information reported to the Department indicated that Child #1 sustained an injury that required medical attention.

Based on interviews and documentation obtained, Child #1 sustained an injury at the facility that required administration of first-aid, but staff did not deem the injury serious enough to seek medical attention during the health-check. Parent #1 sought medical attention for Child #1 and reached out to facility staff to seek and provide information pertaining to the injury.

Although there is not enough information to determine whether the injury sustained required medical attention at the time of the injury, Child #1 did obtain an injury that regardless of the nature of the injury...
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SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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: LBUSD-GRANT CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 191670722
	VISIT DATE: 12/16/2021

NARRATIVE

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...Child #1’s authorized representative should have been notified on the day of the injury. Information obtained during the course of the investigation is that the facility failed to inform Parent #1 that Child #1 sustained an injury at the facility on the day that the injury occurred. Staff #3 and #4 disclosed that Adult #1 was informed of the injury during pick-up time but staff did not inform Parent #1 verbally or in writing. Parent #1 disclosed that they did not receive any phone call or any written report for the injury sustained on the day that it occurred.

Documentation presented by the facility indicates that Parent #1 was provided with an injury report on the day of the incident, yet staff interviewed confirmed that Parent #1 was not present during pick-up time on the day of the incident and therefore it is not possible for the report to have been provided on the day of the incident. During the 12/09/21 visit, LPA was shown a 2nd report that staff filled out but also failed to provide Parent #1 with. The 2nd report was still at the facility and sealed (pictures were taken). Parent #1 confirmed that Adult #1 is the not the parent, legal guardian, or conservator for Child #1 and the facility should have contacted Parent #1 on the day the incident occurred.

The following deficiency listed on the attached deficiencies page is being cited in accordance with California Code of Regulations Title 22.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Exit interview was conducted with Kimberly Kelly, Director, including, but not limited to Provider Rights and Appeal Procedures.

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SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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: LBUSD-GRANT CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 191670722
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/07/2022 Section Cited	1 2 3 4 5 6 7	Observation of the Child (b) Any unusual behavior, any injury or signs of illness requiring assessment and/or administration of first aid by staff shall be reported to the child's authorized representative and recorded in the child's record.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by interviews conducted and documents obtained that the facility failed to report the injury Child #1 sustained at the facility to Parent #1. This poses a potential health, safety, or personal rights risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Rita Ramos	TELEPHONE: (323) 981-3985
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

LIC809 (FAS) - (06/04)

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