191670981-6-20-2023-54-CC-AESA-CSYR2R-20230620123845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191670981
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:39:03 PM

Document Has Been Signed on 06/20/2023 12:39 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:	ROOSEVELTS STATE PRESCHOOL		FACILITY NUMBER:	191670981
ADMINISTRATOR:	AQUINO, SALVADOR		FACILITY TYPE:	850
ADDRESS:	700 N BRADFIELD AVE		TELEPHONE:	(310) 898-6355
CITY:	COMPTON	STATE: CA	ZIP CODE:	90221
CAPACITY: 72	TOTAL ENROLLED CHILDREN: 72	CENSUS: 26	DATE:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Head Teacher Samia Shafiq		TIME COMPLETED:	12:53 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Austin Estrada conducted an unannounced annual required inspection at the above facility. LPA met with Lead Teacher Samia Shafiq who guided analyst on a tour of the facility. Per Lead teacher operation days and hours are 8:00AM-2:00PM Monday-Wednesday, and 8:00AM-12:30PM Thursday. Facility is closed Friday-Sunday. The facility has two classrooms where care is provided. LPA observed 10 children supervised by 3 staff in room 34 and 16 children supervised by 5 staff in room 35. Teacher child ratios were observed, and staff names recorded. The following was observed during the tour of the facility: LPA observed classroom 34 and classroom 35 to be clean and in good repair. The floors were clean, and lighting was in operable condition. There were age appropriate toys and equipment. LPA observed water readily available via a filtered water dispenser. Per Lead Teacher, water bottles are brought from home. LPA observed water bottles to be labeled with children's names. If children do not bring their own water bottles water cups are provided by the facility. LPA observed cubbies/storage area available for children to store their personal belongings. LPA observed a central fire alarm system. LPA did not observe a functioning carbon monoxide detector in either classroom 34 or classroom 35. LPA advised Lead Teacher that there needs to be at least one functioning carbon monoxide detector at the facility. LPA observed Fire extinguisher indicated fully charged last serviced on 4/3/23. First Aid kit was observed and inventoried. Appropriate sinks and toilets were inspected for availability, good repair, water temperature, toilet paper, paper towels, and general sanitation. LPA obseved each classroom to have their own bathrooms. Disinfectants and cleaning solutions were observed to inaccessible to children in care. Per Lead Teacher there are no poisons stored at the facility. LPA advised Lead Teacher that if poisons are stored at the facility they must be locked not only inaccessible to children in care. Napping equipment and bedding were inspected and found to be clean and in operable condition. Per Lead Teacher, bedding sheets are taken home by the children and washed weekly. The isolation area for an ill child is located in the classroom separated from other children. The ill child will use the staff restroom if needed.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Austin Estrada
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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 6

Document Has Been Signed on 06/20/2023 12:39 PM - It Cannot Be Edited

Created By: Austin Estrada On 06/20/2023 at 11:45 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ROOSEVELTS STATE PRESCHOOL	FACILITY NUMBER: 191670981
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.954

Licensure Requirements

Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above: LPA did not observe a functioning carbon monoxide detector at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2023
	Plan of Correction
1 2 3 4	LPA will be provided proof of carbon monoxide detector via email by POC due date.

Type B

Section Cited

HSC

1597.16(a)(1)

Lead Testing

(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above: the facility did not have documentation for lead testing cunducted between 1/1/20-1/1/23 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2023
	Plan of Correction
1 2 3 4	Documentation of a scheduled or completed lead testing will be provided to LPA via email by POC due date.

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 Cook

LICENSING EVALUATOR NAME:

Austin Estrada

LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 06/20/2023 12:39 PM - It Cannot Be Edited

Created By: Austin Estrada On 06/20/2023 at 11:45 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ROOSEVELTS STATE PRESCHOOL	FACILITY NUMBER: 191670981
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216(g)(2)

Personnel Requirements

(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above: LPA did not observe LIC 503 (health screen report) for 8 out of 8 staff present which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2023
	Plan of Correction
1 2 3 4	Documentation of LIC 503 will be provided to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Cook

LICENSING EVALUATOR NAME:

Austin Estrada

LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 06/20/2023 12:39 PM - It Cannot Be Edited

Created By: Austin Estrada On 06/20/2023 at 11:51 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ROOSEVELTS STATE PRESCHOOL	FACILITY NUMBER: 191670981
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101227(5)(A)

This requirement is not met as evidenced by: 101227 Food Services (5) The following shall be offered daily: (A) Full-day programs shall offer a midmorning and a midafternoon snack.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above: Per Lead Teacher only breakfast and Lunch are provided by the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2023
	Plan of Correction
1 2 3 4	Food menu will be provided to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Cook

LICENSING EVALUATOR NAME:

Austin Estrada

LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

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: ROOSEVELTS STATE PRESCHOOL	FACILITY NUMBER: 191670981
	VISIT DATE: 06/20/2023

NARRATIVE

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Per Lead Teacher, no children require medication. Medication is be stored in the classroom in a locked cabinet if needed.
LPA observed the outdoor play area to have age-appropriate toys and material available for children, free of loose, sharp, and/or pointed parts. LPA observed required cushioning under climbing structures to absorb a fall. LPA observed water readily available via water bottles labeled with the children’s names. Per Lead Teacher the outdoor water fountains are currently not used. LPA observed required shade in the outdoor area and did not observe any bodies of water on the premises.
LPA observed the kitchen area, food preparation area, and food storage area to be clean and free of litter, rubbish, rodents, and/or any other vermin. LPA observed refrigerator to be clean and in operable condition. LPA observed items in the refrigerator not to be expired. Food that was not in the original packaging were sealed and labeled with an expiration date. Per Lead Teacher the facility offers breakfast and lunch, LPA advised Lead Teacher that full-day programs shall offer a midmorning and a midafternoon snack and half-day programs shall offer a midmorning or midafternoon snack.
During the inspection, children present was observed to be treated with dignity and respect, observed to be receiving safe, healthful, and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.
LPA observed required posted documentation which included, Facility License, LIC610- Emergency Disaster Plan, Publication (PUB) 393- Notification of Parent Rights, PUB 269- Child Passenger Restraint System, LIC 613A- Notification of Personal Rights and Lunch/Snack Menus. All documents were observed in the classrooms.
LPA observed Sign in/out sheets, LIC 9148 Earthquake Preparedness, Daily Activity Schedule, and Verification of Disaster and Fire Drills (last conducted on 6/5/23).
Children’s records were reviewed for LIC 613A- Personal Rights, Admission Agreement, Immunization Records, LIC 700- Identification and Emergency Information, LIC 701- Physician’s Report, LIC 627- Consent for Medical Treatment, and LIC 995A Notification of Parents’ Rights. All records were observed to be complete.
Staff records were reviewed for approved Pediatric First Aid and CPR certification, staff qualifications, LIC 508-Criminal Record Statement, LIC 503- Health Screening Report, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, and LIC 9108- Statement of Child and Mandated Reporter Training Certificate. There is at least one person trained in CPR and Pediatric First Aid present during this inspection. LPA did not observe LIC 503 for 8 out of 8 staff present. LPA advised Lead Teacher that all staff shall have LIC 503 completed and

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Austin Estrada
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: ROOSEVELTS STATE PRESCHOOL	FACILITY NUMBER: 191670981
	VISIT DATE: 06/20/2023

NARRATIVE

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available for review during inspections.
Lead Poisoning Facts Flyer (PUB 515) – All Licensees (Child Care Centers) must provide the following flyer to parents and families upon enrolling or re-enrolling any child. LPA provided Lead Teacher with PIN 21-21-CCP: Release of the Written Directives for Lead Testing of Water in Licensed Child Care Centers Per AB 2370. Facility last had lead water testing conducted on 6/1/18. LPA advised Lead Teacher that lead testing was to be conducted on or after 1/1/20-1/1/23.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
LPA provided and discussed PIN 23-06-CCP Information Regarding Brightly Colored Fentanyl, Also Referred to as “Rainbow Fentanyl”.
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
Lead Teacher was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
Based on the LPA’s observations, interviews and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety. Deficiencies include 4 type B violations.
A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty. Exit interview was conducted and report was reviewed with the Lead Teacher. Appeal rights were discussed and provided to the Lead Teacher.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Austin Estrada
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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