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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191805782
Report Date: 08/23/2022
Date Signed: 08/23/2022 02:49:22 PM


Document Has Been Signed on 08/23/2022 02:49 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:CARVER STATE PRESCHOOLFACILITY NUMBER:
191805782
ADMINISTRATOR:WILLIAMS, PAULINEFACILITY TYPE:
850
ADDRESS:1425 E. 120TH ST.TELEPHONE:
(310) 898-6150
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY:40CENSUS: 23DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mariana Godinez, Facility RepresentativeTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 3/23/22 at 9:00 AM. LPA met with Mariana Godinez, Facility Representative (FR).

There were 23 children and four staff present when LPA arrived. This facility has two preschool programs, one full day, operating 8:00AM to 3:00PM in Room K-E and an AM program, operating from 8:00AM to 11:00AM in Room K-F. Facility is on the campus of Carver Elementary. All individuals present have obtained a criminal record clearance or criminal record exemption as a condition of employment with Compton Unified School District.

LPA toured Classrooms K-E and K-F. Classroom furniture was in good condition, free of loose, sharp and/or pointed parts. The floors and surfaces in the classrooms were clean and safe. The black rugs in Room K-E were observed to lifted and bunched up creating tripping hazards in two different areas of the classroom. LPA observed cleaning supplies in Room K-E under children's sink with unlatched child lock. Staff One (S1) locked the cabinet during inspection. LPA observed cleaning supplies in Room K-F under the children's sink with no lock. Staff Two (S2) removed items and made made them inaccessible. Water is made readily available by via water bottles brought from home and provided by facility. LPA observed extra water bottles and a filtered water dispenser in each classroom. Water fountains have also been cleared for use. LPA observed operable water fountains in each classroom. Children have cubbies to store personal belongings separate from each other. Full day classroom, K-E was observed to have cots for napping. Per S1, bedding is brought by families and taken home to be washed once a week. Per S2 there is currently one child with medication. LPA observed Epinephrine in the classroom's First Aid kit without a labeled box or prescription.

LPA toured the children’s restrooms. Each classroom has their own restroom. LPA observed a changing table in Room K-E with books and toys stored on top of it. S1 informed that no children use the changing table at the ---------------------PAGE 1
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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 7


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: CARVER STATE PRESCHOOL
FACILITY NUMBER: 191805782
VISIT DATE: 08/23/2022
NARRATIVE
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moment. LPA advised that the changing table be kept clear of toys and material for sanitary reasons. LPA also observed a loose cable cord along the bottom of the wall in the second restroom in Room K-E that can be a tripping or choking hazard. LPA observed operable sinks and toilets.

At 10AM LPA toured the outdoor play area. Outdoor area was observed to have age appropriate toys and material for children. LPA observed required cushioning under climbing structure to absorb fall. LPA did not observe shade in the outdoor space. Per FR, a tree was cut down and all pop-up tents that were purchased have blown away. FR will discuss shade with District Director. During inspection LPA walked the yard and observed multiple holes in the grass/dirt area and protruding irrigation/sprinklers that are a tripping hazard for children. LPA also observed food wrappers, bottle caps, black and mild wrapper, broken glass, broken plastic and other debris scattered throughout the yard. Water was observed to be readily available via water fountains. Outdoor area is also used by the kindergarten (not part of licensed facility). Per FR, a waiver was requested. LPA did not observe an outdoor waiver on site.

LPA reviewed Sign In/Out sheets located in each classroom. All children present were signed in with the guardian's full signature, date, and time of drop off.

LPA observed required posted documentation which included, Facility License, Publication (PUB) 393- Notification of Parent Rights, PUB 269- Child Passenger Restraint System, Licensing Form LIC 613A- Notification of Personal Rights. Facility records were reviewed for 9148- Earthquake Preparedness form and (LIC) 610- Facility Disaster Plan. Disaster drill was last drill conducted in May 2022 before summer vacation. Facility has just reopened 8/18/22 with disaster drill scheduled for next week.

Children’s records were reviewed. Physical files are not kept on site. FR printed out files for LPA review. Children’s records were reviewed for Licensing Form (LIC) 700- Emergency Identification Record, LIC 627- Consent for Medical Treatment, Immunization Records, LIC 995 Notification of Parents’ Rights, LIC 701- Physician’s Report, LIC 613A- Personal Rights, and signed Admissions Agreement. All documents were observed.

Staff records were not able to be reviewed. Per, FR all staff files are located at the Compton Unified District Office, not on site. LPA informed that Preschool staff files need to be available for LPA review.
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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: CARVER STATE PRESCHOOL
FACILITY NUMBER: 191805782
VISIT DATE: 08/23/2022
NARRATIVE
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Kitchen located on the elementary campus. Facility provides Breakfast and Lunch. Food is not cooked at the facility. Prepackaged food is delivered daily. Extra food is discarded at the end of the day. Kitchen was observed to be clean, free of litter, insects and rodents. LPA reminded FR that all trash cans in the classroom, outdoors and in the kitchen need tight fitting lids for solid waste. Cleaning supplies are stored separate from the food. Carbon Monoxide detector is wired with smoke/fire alarm.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

LPA observed that facility is implementing COVID-19 precautions and procedures as required by Compton Unified School District and the Department of Public Health.

Incidental Medical Services (IMS):
This facility provides Incidental Medical Services- IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personal, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Based on the LPA’s observations 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

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.

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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: CARVER STATE PRESCHOOL
FACILITY NUMBER: 191805782
VISIT DATE: 08/23/2022
NARRATIVE
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Facility representative was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

A notice of site visit was given and must remain posted for 30 days.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

Exit interview conducted and report was reviewed with the Facility Representatives, Mariana Godinez.

SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/23/2022 02:49 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CARVER STATE PRESCHOOL
FACILITY NUMBER: 191805782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101238.2(d)(2)
Outdoor Activity Space
(d) The surface of the outdoor activity space shall be maintained: (2) Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed broken glass, broken plastic with sharp edges, multiple holes in the dirt and grass, protruding sprinklers, inappropriate wrappers, and other debris, Which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Per FR a work order will be put in to the district to fill the holes, the plant manager will be notified about the cleanliness of the yard and a plan will be put on place with high priority. A checklist will be created for preschool teachers to walk the yard and scan for hazardous items daily while outside. FR will email work order and checklist to LPA by POC date 8/26/22.
Type A
Section Cited
CCR
101226(e)(2)
Health-Related Services
(2) All prescription and nonprescription medications shall be maintained with the child's name and shall be dated.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for one out of one children. LPA observed Epinephrine in classroom with no label or prescription, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2022
Plan of Correction
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During inspection Epinephine out of the box in the classroom was brought to the nurses office and put back in original labeled box with prescription (cleared during inspection). FR, will get a medication box for the classroom to store epinephine with labeled box and documentation.

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 CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 08/23/2022 02:49 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CARVER STATE PRESCHOOL
FACILITY NUMBER: 191805782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238.2(b)(1)
Outdoor Activity Space
(1) Provide a shaded rest area for the children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA did not observe shade for children, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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FR will speck with Child Development director to obtain shade for the outdoor yard. FR will email proof of shade by POC date 9/23/22.
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four out of four files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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Per FR, she will ask staff for a copy of current CPR and 1st aid and email a copy to LPA by POC date 9/23/22

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 CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 08/23/2022 02:49 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CARVER STATE PRESCHOOL
FACILITY NUMBER: 191805782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(d)
Personnel Records
(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on record review, the licensee did not comply with the section cited above in four out of four files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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2
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Per FR, she will have staff gather all information needed for file make sure files are avalible for LPA review. FR will email document to LPA by POC date 9/23/22.
Type B
Section Cited
CCR
101221(d)
Child's Records
(d) All children's records shall be available to the Department to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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2
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Cleared during inspection

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 CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7