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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870741
Report Date: 01/15/2020
Date Signed: 01/15/2020 01:57:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:HAWAIIAN AVENUE EARLY EDUCATION CENTERFACILITY NUMBER:
191870741
ADMINISTRATOR:AGUET, DEBORAHFACILITY TYPE:
850
ADDRESS:501 HAWAIIAN AVE.TELEPHONE:
(310) 834-7186
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY:117CENSUS: 107DATE:
01/15/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Deborah AguetTIME COMPLETED:
02:15 PM
NARRATIVE
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On 01/15/2020, Licensing Program Analyst made an unannounced visit for the purpose of conducting a follow up Case Management visit to interview the Director regarding an Unusual Incident that occurred and was reported to licensing on 11/19/2019. Director was at an off-site training on LPA Starks previous visit to the location.

Based on interviews conducted and information obtained the Director observed Staff #1 hit Child #1 with an open hand. Staff was bringing C1 into the classroom from outdoors, other children and staff had not began returning into the class as yet. S1 did not observe the Director in the class. Director told Staff 1 to put child down and immediately go to the Director's office. Director checked child for marks or bruising, none were observed. Additional staff and other children came into classroom, Director spoke with Staff 1 and attempted to contact parents at the time of occurrence and completed a Suspected Child Abuse Report. Staff 1 no longer can substitute at this location.
Based on this information the Personal Rights of the child were violated.

Type A deficiency is being cited. LIC 809, 809D, LIC9224 and Notice of Site Visit are being issued. **The facility will provide a copy of this report to the parents of children currently enrolled in the program and sign a LIC9224 - Acknowledgment of Receipt for this report. This process will also be followed for any child that enrolls within the next 12 months from the date of citation. This report will also be posted for 30 days along with the Notice of Site visit. Once the Plan of Correction letter is received it will be posted for 30 day as well. **
SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2020
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HAWAIIAN AVENUE EARLY EDUCATION CENTER
FACILITY NUMBER: 191870741
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2020
Section Cited

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PERSONAL RIGHTS - To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or
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toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

This is not met by the evidence of the Director observing Staff 1 hit Child 1
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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: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2020
LIC809 (FAS) - (06/04)
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