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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191890346
Report Date: 08/23/2023
Date Signed: 08/23/2023 02:06:39 PM


Document Has Been Signed on 08/23/2023 02:06 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:HILLARY BROADOUS EARLY EDUCATION CENTERFACILITY NUMBER:
191890346
ADMINISTRATOR:MERMELL, RACHELFACILITY TYPE:
850
ADDRESS:11736 BROMONT AVE.TELEPHONE:
(818) 897-2009
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY:118CENSUS: 47DATE:
08/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Jennifer Maddocks, PrincipalTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lilia Hernandez conducted an unannounced case management inspection due to incidents that occurred on 07/20/2023 and 8/14/2023. LPA arrived at the facility at 9:06AM and met with Jennifer Maddocks, Principal, who guided LPA on a tour of the facility. There were 47 children and 16 staff present upon arrival.

The purpose of the visit was to follow-up on two separate incidents that were reported to the Department. The first incident was reported on 07/25/2023 by telephone. The second incident was reported on 8/17/2023 by email.

During the inspection, Principal disclosed to LPA that on 08/21/2023, Classroom 4 and the children's restrooms that are located in the classroom sustained water damage from the storm that occurred on 8/20/2023. Per principal, damaged ceiling tiles were replaced. LPA observed that repairs had already been made to in the bathrooms.(photos taken) LPA also observed floor tile to be damaged. LPA observed duct tape placed on the corner of the tiles until repairs can be made. Per principal, flooring will be replaced on 8/25/2023 and repaired are scheduled to be complete by end of day 8/27/2023. Principal was advised to submit an unusual incident report and a statement outlining the timeline of repairs.

Information reported to the Department for the incident that occurred on 7/20/2023 indicated that parent reported that Child#1 (C1) personal rights may or may not have been violated. C1 last day of attendance was 7/29/2023.

At this time, incident that occurred on 7/20/2023 will need further investigation. ---Page 1 of 2
SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia HernandezTELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: HILLARY BROADOUS EARLY EDUCATION CENTER
FACILITY NUMBER: 191890346
VISIT DATE: 08/23/2023
NARRATIVE
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Information reported to the Department for the incident that occurred on 8/14/2023 indicated that Child#2 (C2) during freeplay walked by a shelf and knocked a toy to the ground. When C2 walked around the shelf to pick up the toy, C2 fell. Staff 2 and Staff 3 witnessed the fall. C2 mouth was bleeding and Staff 3 administered first aid. Guardian was notified and issued a head injury report and advised to seek medical attention for child.

C2 returned to care on 8/15/2023 with a doctor's note. No restrictions were documented on the doctor's note.

LPA Hernandez obtained child rosters and other pertinent documentation for the incidents during the visit.

Based on LPA's record review, the facility did not reported all three unusual incidents to the Department as specified in the regulation requirements. 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.

The following deficiencies listed on the attached deficiencies page are being cited in accordance with California Code of Regulations Title 22.

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

Exit interview conducted and report was reviewed with Jennifer Maddocks, Principal.
---Page 2 of 2
SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia HernandezTELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/23/2023 02:06 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: HILLARY BROADOUS EARLY EDUCATION CENTER
FACILITY NUMBER: 191890346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2023
Section Cited
CCR
101212(d)(1)(C)

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Reporting Requirements (d)Upon the occurrence...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...Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.

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Per Principal, reporting requirements will be reviewed with staff. Meeting agenda, signed attendance sheet will be emailed to by POC due date.
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This requirement is not met as evidenced by:
Based on record review, the license did not report unusual incidents that occurred on 7/20/23, 8/14/23, and 8/21/23 on next working day which poses a potential Health, Safety, and Personal Rights risk to persons in care.
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Type B
08/25/2023
Section Cited
CCR101237(a)

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Alterations to Existing Buildings or New Facilities (a) Prior to construction or alterations, the licensee shall notify the Department of the proposed change(s).
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Per principal, incident report and timeline of repairs will be submitted by emial to LPA by POC due date.
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This requirement is not met as evidenced by:
Based on interview, the license did not report alterations to Room 4 prior to proposed changes which poses a potential Health, Safety, and Personal Rights risk to persons 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: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia HernandezTELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3