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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191890344
Report Date: 02/15/2022
Date Signed: 02/15/2022 10:37:30 AM


Document Has Been Signed on 02/15/2022 10:37 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:EVERGREEN EARLY EDUCATION CENTERFACILITY NUMBER:
191890344
ADMINISTRATOR:XOCHITL SANCHEZFACILITY TYPE:
850
ADDRESS:1027 N EVERGREEN AVETELEPHONE:
(323) 269-0406
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY:162CENSUS: 53DATE:
02/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Office Manager, Mayra Guzman &
Principal, Xochitl Sanchez		TIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mireya García conducted an announced Case Management Deficiencies Inspection to address deficiency discovered during visit conducted on December 23, 2021. Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPA met with Office Manager, Mayra Guzman who guided LPA on a tour of the facility. The Principal, Xochitl Sanchez was not available for tour. There were 53 children observed to be present at the facility during this inspection. The purpose of this report is to address concerns regarding Reporting Requirements.

On December 23, 2021 During interviews conducted with day care staff disclosures reveal that an unusual incident occurred at the facility on December 16, 2021, a day care parent alleges that child #1 disclosed facility staff #1 hurt child. Licensee representative did not report this to the Department. The facility is being cited for failure to report required information to the Department within the required 24 hours.

The deficiency listed on the following page is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809d.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Principal, Xochitl Sanchez.


Report ends here page 1 of 1.

SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya GarciaTELEPHONE: (323) 981-3390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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 02/15/2022 10:37 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: EVERGREEN EARLY EDUCATION CENTER
FACILITY NUMBER: 191890344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2022
Section Cited

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101212 Reporting Requirements- (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported shall include the following: ... (D) Any suspected physical or psychological abuse of any child. This requirement is not met as evidence by:
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LPA's investigation findings reveal that an unusual incident occurred at the facility on December 16, 2021, a day care parent alleges that child #1 disclosed facility staff #1 hurt child. Licensee representative did not report this incident as required to the Department. This poses a potential 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: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya GarciaTELEPHONE: (323) 981-3390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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