191890344-2-15-2022-33-CC-BVON-CBQNMZ-20220217093554

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191890344
Report Date: 02/15/2022
Date Signed: 02/15/2022 10:26:48 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2021 and conducted by Evaluator Mireya Garcia

COMPLAINT CONTROL NUMBER: 33-CC-20211220150752

FACILITY NAME:	EVERGREEN EARLY EDUCATION CENTER		FACILITY NUMBER:	191890344
ADMINISTRATOR:	XOCHITL SANCHEZ		FACILITY TYPE:	850
ADDRESS:	1027 N EVERGREEN AVE		TELEPHONE:	(323) 269-0406
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90033
CAPACITY:	162	CENSUS: 53	DATE:	02/15/2022
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Office Manager, Mayra Guzman & Principal, Xochitl Sanchez		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Child sutstained an unexplained injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mireya García arrived unannounced at the facility for the purpose of conducting a follow up complaint investigation to deliver findings regarding the allegation listed above. 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.

Information provided by the complainant alleges that child sustained an unexplained injury while in care.

REPORT CONTINUES ON NEXT PAGE 1 OF 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya Garcia	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 33-CC-20211220150752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 02/15/2022

NARRATIVE

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During this investigation, LPA Garcia obtained; copies of LIC 9040 Children’s roster dated 12/23/2021, Classroom #5’s Roster date range: 12/13/2021- 12/17/2021, Certificate for completing the California Child Abuse Mandated Reporter Online Training for Child Care Providers for Staff #1, blank student incident report from home form, notebook observation notes from Staff #5 dated 11/29/21 & 12/13/21 regarding Child #1 and conducted interviews with seven (7) day care staff, four (4) day care parents who attend facility and attempted to interview children and the child in questioned.

Pertaining to the allegation of child sustained an unexplained injury while in care, all interviews conducted with staff determined staff denied observing or having knowledge of any child being hit while in care by any staff. Staff #1, #3, #4, #5, #6 and #7 confirm seeing bruise on child #1. Staff #7 statements concur with staff #1 who disclosed witnessing child #1’s bruises on arm when staff #1 assisted child during hand washing. Staff #5 disclosed reporting bruises to child #1’s parent however, student incident report from home was not given to parent. All four (4) families interviewed denied their child being hit or staff hitting.

In review of records, LPA Garcia observed Classroom #5’s Child Roster date range: 12/13/2021- 12/17/2021 with documented note; bruise on Child #1’s right arm by elbow initialed by Staff #1. The Child Roster date range: 12/13/2021- 12/17/2021 identifies children’s injuries observed and documented by staff which includes; child’s #/name, injury (scratch, bruise, scrape), location of injury, date and staff initials. REPORT CONTINUES ON NEXT PAGE 2 OF 3.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya Garcia	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 33-CC-20211220150752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 02/15/2022

NARRATIVE

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In addition, in review of classroom #5’s notebook handwritten notes from Staff #5 documents on 11/29/21- Child #1 came in with a bruise behind right ear and on 12/13/21- Child #1 came to school with small bruises on right inner arm.

Based on the interviews conducted and records review, at this time there is not enough evidence to support the above allegation.

This agency has investigated the complaint alleging that child sustained an unexplained injury while in care. Although the allegation may had happened or is valid; Based on interviews conducted; there were no witnesses to the allegation and child #1 was not able to be located for interview, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the allegation is deemed Unsubstantiated. Should additional information become available in the future, this investigation may be reopened.

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 3 OF 3.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya Garcia	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 3