191890344-6-21-2023-33-CC-MGAA-CSZVBR-20230621161759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191890344
Report Date: 06/21/2023
Date Signed: 06/21/2023 04:18:31 PM

Document Has Been Signed on 06/21/2023 04:18 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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

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: 50	DATE:	06/21/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Yvonne Gutierrez, Teacher		TIME COMPLETED:	04:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Mireya García conducted an unannounced Case Management inspection due to an incident that was reported to the Department on April 03, 2023. LPA met with Teacher, Yvonne Gutierrez who guided LPA on a tour of the facility. Principal, Xochitl Sanchez was not present during this inspection. Census was taken.

The purpose of this report is to address the investigative findings of the unusual incident report that was reported to the Department.

On April 03, 2023, an incident was self reported to the Department via telephone by the facility who reported a parent alleges that child's personal rights were violated while in care.

During the inspection conducted on June 13, 2023, LPA Garcia conducted interviews with Principal, four (4) day care children, child in question and telephone interview with Parent #1.

During the course of the investigation, LPA obtained a copy of the LIC9040 Children roster dated 06/13/23, LIC 855 written declaration statements from Staff #1 and Staff #2, copy of the conference memorandum held on 04/20/23 signed by Staff #1 from Principal and conducted interviews with Principal, three (3) staff, five (5) day care children and parent of child in question.

REPORT CONTINUES ON NEXT PAGE 1 OF 2.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya Garcia	TELEPHONE: (323) 981-3390
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN EARLY EDUCATION CENTER	FACILITY NUMBER: 191890344
	VISIT DATE: 06/21/2023

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Interview with Staff #1 confirm that on April 03, 2023, during pick up time child #1 was pressing intercom buzzer button, staff #1 instructed child to stop pressing button 2-3 times before staff #1 placed their hand over child #1’s hand and moved child’s hand away from the intercom buzzer. Child #1 demonstrated how staff #1 removed child’s hand to Staff #2, Principal and LPA Garcia. Child #1 disclosed staff #1 hurt child's feeling when staff #1 placed their hand over child’s hand and moved child’s hand away from intercom buzzer. This poses a potential health and safety risk to children in care. Title 22 Regulation Section 101223 Personal Rights states (a) The licensee shall ensure that each child is accorded the following personal rights: (3) 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 toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

The following deficiency is being cited in accordance with Title 22 of the California Code of Regulations. Please refer to LIC809D for documentation of deficiency cited.

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

Exit interview conducted and report was reviewed with facility representative, Yvonne Gutierrez.

END OF REPORT: PAGE 2 OF 2.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya Garcia	TELEPHONE: (323) 981-3390
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/21/2023 04:18 PM - 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
L.A. DAY CARE-EAST, 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: 06/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/05/2023 Section Cited CCR 101223(a)(3)	1 2 3 4 5 6 7	101223-Personal Rights: (a) The licensee shall ensure that each child is accorded the following personal rights: (3) 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 toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Per Teacher, Principal will provided training to all staff in regards to personal rights to ensure that staff is in compliance with Title 22 Regulations.
	8 9 10 11 12 13 14	Based on interviews conducted by LPA Mireya Garcia on June 13, 2023 and June 21, 2023, it was determined that the personal rights of Child #1 were violated by Staff #1. This poses a potential health and safety risk to children in care.	8 9 10 11 12 13 14	Per Teacher the Principal will submit via email to LPA Garcia training material, agenda and staff sign in sheet by POC due date 7/5/23, in order to clear this citation.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya Garcia	TELEPHONE: (323) 981-3390
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC809 (FAS) - (06/04)

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