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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870566
Report Date: 05/18/2023
Date Signed: 05/18/2023 01:31:00 PM


Document Has Been Signed on 05/18/2023 01:31 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: 18DATE:
05/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Christina Olivares, Supervisor TIME COMPLETED:
01:45 PM
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On May 18, 2023, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced Case Management Inspection for above location. The purpose of the inspection is to follow up on an incident that occurred on 05/12/2023 and was reported timely to the department by the next business day (05//15/2023). A COVID-19 risk assessment was conducted prior to entering the facility. LPA met with Supervisor Christina Olivares who guided LPA on a tour of the facility.

Brief Summary: On 05/12/2023, Child #1 (C1) was jumping on a net located in the grass area. The net was not meant for jumping and teacher asked C1 to make another choice. C1 went back to the net and was redirected again. C1 went back to the net for the third time and started to jump and a part of the net was stuck on C1's shoulder. C1 stated that the area around her neck was hurting, teacher observed the neck to be red. Director asked C1 to move her neck and arms around, C1 did not complain of pain. Throughout the day C1 did not complain of pain. The facility applied an ice pack and notified Parent #1 (P1). On 05/15/2023, P1 called the facility stating that over the weekend C1 was saying her shoulder hurt. P1 took C1 to urgent care where it was determined that C1 had a fractured neck (broke collarbone).

During the inspection LPA interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), obtained a copy of incident report, obtained a copy of staff and children sign in sheets and a copy of C1's emergency card. LPA was unable to interview C1 or any other children due to the children napping.

Per S1, S2, S3 and S4, C1 was jumping in the grass area near the play house. Per S2, she redirected C1 multiple times from jumping on the net. Per S2, C1 continued to come back and jump on the net and on the final jump S2 observed C1 fall after jumping on the net. S2 stated that she went to check on C1 when she fell, S2 noticed that her neck was red. S2 stated that C1's neck was caught in the net. S4 was coming back from break when S2 went to explain what had happened to C1.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
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: CENTRO DE NINOS, MARAVILLA
FACILITY NUMBER: 191870566
VISIT DATE: 05/18/2023
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S2 brought C1 into the office where C1 was provided an ice pack and C1's parent was called and messaged through learning genie. Per S1, S2, S3 and S4, C1 did not complain of pain throughout the day aside from the incident first occurred. Per supervisor, C1 returned to the facility on 05/17/2023 with restrictions of no physical activity. LPA observed sign in sheets for children and staff that were present on the day of the incident (05/12/2023). There were 19 children with 3 staff member and a floater teacher (4 staff in total).

There are no deficiencies being given today 05/18/2023. This incident was an accident that occurred fast and was unable to be prevented. LPA observed the grass area where incident occurred to be in good repair.

An exit interview was conducted and a copy of this report was provided to supervisor along with Notice of Site Visit.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
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