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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870566
Report Date: 01/27/2023
Date Signed: 01/27/2023 02:55:45 PM


Document Has Been Signed on 01/27/2023 02:55 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:CENTRO DE NINOS, MARAVILLAFACILITY NUMBER:
191870566
ADMINISTRATOR:LETICIA SANTOS CUEVASFACILITY TYPE:
850
ADDRESS:4850 E. CESAR CHAVEZ AVENUETELEPHONE:
(323) 268-4600
CITY:LOS ANGELESSTATE: CAZIP CODE:
90022
CAPACITY:68CENSUS: 52DATE:
01/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Christina Olivares-Iida, Site SupervisorTIME COMPLETED:
01:40 PM
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On January 27, 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, Christina Olivares-Iida who guided LPA on a tour of the facility. LPA observed 52 children in care with 12 staff. The purpose of this inspection is to follow up on an incident that occurred on 01/13/2023; the incident was reported timely to the department.

Brief Summary of Incident: On 01/13/2023 at approximately 9AM, Child #1 (C1) was walking up the stairs of the play structure when he tripped and hit his head on the yellow handle of the structure. C1 obtained a bump on his head. C1 did not require medical attention.

During this inspection LPA interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3) and obtained a copy C1's emergency contact form.

At this time this incident requires further investigation.

An exit interview was conducted and a copy of this report was provided to Site Supervisor, Christina Olivares-Iida a Notice of Site Visit was provided.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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