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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191806528
Report Date: 03/06/2023
Date Signed: 03/06/2023 11:12:12 AM


Document Has Been Signed on 03/06/2023 11:12 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:CHILDREN'S HOSPITAL CHILD DEVELOPMENT CENTER (PS)FACILITY NUMBER:
191806528
ADMINISTRATOR:VERONICA MONTANO SANCHEZFACILITY TYPE:
850
ADDRESS:4601 SUNSET BOULEVARDTELEPHONE:
(323) 361-4601
CITY:LOS ANGELESSTATE: CAZIP CODE:
90027
CAPACITY:89CENSUS: 19DATE:
03/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Marife Adriano, Site SupervisorTIME COMPLETED:
11:30 AM
NARRATIVE
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On 03/06/2023, Licensing Program Analyst (LPA) Monique Ayala, conducted an unannounced Case Management inspection at the above facility. A COVID-19 risk assessment was conducted prior to entering the facility. LPA met with Site Supervisor, Marife Adriano who guided LPA on a tour of the facility. LPA observed 19 children in care. The purpose of the inspection is to follow up on an unusual incident report that occurred on 03/01/2023 and was filed with the department on 03/01/2023. The report was filed in a timely manner.

Brief summary: On 03/01/2023 at approximately 8:30AM, Child #1 (C1) and Child #2 (C2) were left in preschool classroom #1 unattended for approximately 30 seconds by staff #1 (S1). C1 and C2 were found by Staff #2 (S2).

During this inspection, LPA interviewed S2, C1 and reviewed video footage of the incident.

During interviews, it was disclosed that S2 was assisting S1 to look for C1. While looking for C1, S2 discovered that C2 was also missing. During the time of the incident S1 had 4 children in her care. LPA interviewed C2 who stated he was alone with C1. After reviewing video surveillance footage, C1 and C2 were left unattended for approximately 33 seconds in the classroom. LPA did not interview S1 as she was not present at the facility and LPA attempted to interview C1 but was unable to.

Based on interviews conducted and observation, the facility is being cited a Type A deficiency under Ttitle 22 Regulation, Responsibility for Providing Care and Supervision 101229(a)(1), please see LIC809D.

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).
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHILDREN'S HOSPITAL CHILD DEVELOPMENT CENTER (PS)
FACILITY NUMBER: 191806528
VISIT DATE: 03/06/2023
NARRATIVE
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Acknowledgement of Receipt (LIC 9224 form) must be maintained in each child’s file immediately upon receipt from parent.

An exit interview was conducted was conducted and copy of this report was provided to Marife Adriano ta along with Notice of Site Visit and appeal rights.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/06/2023 11:12 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: CHILDREN'S HOSPITAL CHILD DEVELOPMENT CENTER (PS)
FACILITY NUMBER: 191806528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2023
Section Cited

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 Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time, ... Supervision shall include visual
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Director will hold a staff meeting discussing supervision and provide a copy of sign in sheet to LPA along with meeting agenda by POC date 03/17/2023.
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observation. This requirement was not met as evidence by: Based on interviews and observations, C1 and C2 were left in the classroom unattended by S2 for approximately 30 seconds. This poses an immediate health and safety risk to children in care.
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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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
LIC809 (FAS) - (06/04)
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