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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191806528
Report Date: 05/29/2024
Date Signed: 05/29/2024 02:33:32 PM


Document Has Been Signed on 05/29/2024 02:33 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:CHILDREN'S HOSPITAL CHILD DEVELOPMENT CENTER (PS)FACILITY NUMBER:
191806528
ADMINISTRATOR:LAURA HERNANDEZFACILITY TYPE:
850
ADDRESS:4601 SUNSET BOULEVARDTELEPHONE:
(323) 361-4601
CITY:LOS ANGELESSTATE: CAZIP CODE:
90027
CAPACITY:89CENSUS: 13DATE:
05/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Marife Adriano, Site Supervisor TIME COMPLETED:
02:45 PM
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On May 29, 2024, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced Case Management inspection. 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 13 children in care.

The purpose of the inspection is to conduct a health and welfare check to ensure the health and safety of the children in care are met. LPA observed video footage of Staff #1 (S1), handling Child #1 (C1) in an inappropriate manner. The classroom was in transition from lunch to nap time. S1 walked C1 over to a cot that did not belong to C1. C1 sat on the floor at the end of the cot. C1 was observed to attempt to lay on the floor when S1 grabbed C1 from the left arm and left leg, picked up C1 and placed C1 on top of the cot. LPA interviewed S1 who stated she does not recall doing this action. LPA interviewed Staff #2 (S2) and Staff #3 (S3) who also saw the video footage and stated that this not a normal practice within the facility. Per S3, there has been a meeting with all staff on 05/24/2024 to review proper handling with children.

Based on interviews conducted and video footage review the facility is being cited a Type A deficiency in accordance with Title 22 Regulations, Personal Rights 101223(a)(2). Upon receipt of a Type A deficiency 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). Acknowledgement of Receipt (LIC 9224 form) must be maintained in each child’s file immediately upon receipt from parent.

An exit interview was conducted and a copy of this report was provided to Site Supervisor, Marife Adriano along with Appeal Rights and Notice of Site Visit. Notice of Site Visit must be posted for 30 days.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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 05/29/2024 02:33 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 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: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2024
Section Cited
CCR
101223(a)(2)

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Personal Rights: The licensee shall ensure that each child is accorded the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidence by: Based on interviews and
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Per director, S1 has been placed on administrative leave. Per director there was an in service meeting with all staff on 05/24/2024 reviewing supervison and personal rights. Director will submit sign in sheets of staff that attedned to LPA by POC date (06/07/2024).
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video footage review. S1 was observed to handle C1 in an inappropriate manner. S1 grabbed C1 by the arm and leg, lifted C1 and placed C1 on a cot. This poses an immediate health and safety risk for 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: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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