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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191890344
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:28:40 PM

Document Has Been Signed on 08/08/2024 03:28 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:EVERGREEN EARLY EDUCATION CENTERFACILITY NUMBER:
191890344
ADMINISTRATOR/
DIRECTOR:		XOCHITL SANCHEZFACILITY TYPE:
850
ADDRESS:1027 N EVERGREEN AVETELEPHONE:
(323) 269-0406
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY: 162TOTAL ENROLLED CHILDREN: 78CENSUS: 49DATE:
08/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Xochitl Sanchez, Principal TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Roxana Lopez conducted an unannounced Case Management inspection due to 4 incidents that were reported to the Department. LPA met with Principal Xochitl Sanchez who guided LPA on a tour of the facility. Census was taken.

On November 3rd, 2023, an incident was self reported to the Department via Email by the facility who reported child #1 fell and had a cut on left eye lid.



On November 8th, 2023, an incident was self reported to the Department via Email by the facility who reported parent alleged that child # 2 personal rights were violated.

On January 25th, 2024 an incident was sefl reported to the Department via Email by the facility who reported parent alleged that child # 3 personal rights were violated.

On June 6th, 2024 an incident was sefl reported to the Department via Email by the facility who reported child # 4 fell and had a cut on right eye lid.

All reports were reported within the required 24 hours. The purpose of the inspection was to obtain additional information regarding the incidents reported to the Department. During the inspection, LPA Lopez conducted interviews and obtained declarations from staff.

Regarding incidents that occurred on November 3rd, 2023 interviews were conducted, incident was observed by staff and first aid was provided.
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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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
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
VISIT DATE: 08/08/2024
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Regarding incident that occurred on November 8th, 2023 interviews were conducted no disclosures were made- LAUSD conducted investigation and was found unfounded.

Regarding incident that occurred on January 25th, 2024 interviews were conducted no disclosures were made- LAUSD conducted investigation and was found unfounded.

Regarding incident that occurred on June 4th, 2024 interviews were conducted, incident was observed by staff and first aid was provided. Child was taken to the doctor by parents- child returned the next day with no restrictions.

At this time the licensee is in compliance with California Code of Regulations Title 22. No deficiencies 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, Xochitl Sanchez

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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