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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191890344
Report Date: 11/01/2023
Date Signed: 11/01/2023 10:30:57 AM


Document Has Been Signed on 11/01/2023 10:30 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: 57DATE:
11/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Xochitl Sanchez, PrincipalTIME COMPLETED:
10:45 AM
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On November 1, 2023, Licensing Program Analysts (LPAs), Monique Ayala and Staicy Perry conducted an unannounced case management inspection. The purpose of the inspection is to follow up on two incident reports that filed on 10/16/2023 and were reported to the department in a timely manner. A COVID-19 risk assessment was conducted prior to entering the facility. LPAs met with Principal, Xochtil Sanchez who guided LPAs on a tour of the facility. LPAs observed 57 children in care with 14 staff members.

Brief summary of incident #1: On 10/16/23 parent of Child #1 (C1), told the principal that Staff #1 (S1) hit the C1 on the head with her hand. This incident allegedly occurred sometime last week.

Brief summary of incident #2: This morning on 10/16/2023 Child #2 (C2) parent disclosed to facility that S1 scratched C2's arm around a 2 weeks ago. Parent also stated this S1 pulled a pillow away from the child in a rough manner.

During this inspection LPAs interviewed Child #2 and Child #3, C#1 did not want to be interviewed. LPAs interviewed Staff #2 (S2) to Staff #4 (S4), S1 was not present at the facility and LPAs were unable to interview. LPAs obtained a copy of the facility roster and S#1 contact information.

At this time the two incident reports require further investigation. There will be no deficiencies cited today, 11/01/2023.

An exit interview was conducted and a copy of this report was provided to the principal, along with Notice of Site Visit. Notice of Site Visit must be posted for 30 days.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
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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