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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191890442
Report Date: 03/15/2022
Date Signed: 03/15/2022 11:18:07 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/15/2021 and conducted by Evaluator Liana Stepanyan
PUBLIC
COMPLAINT CONTROL NUMBER: 12-CC-20211115150552
FACILITY NAME:PINEWOOD AVENUE EARLY EDUCATION CENTERFACILITY NUMBER:
191890442
ADMINISTRATOR:RACHEL MERMELLFACILITY TYPE:
850
ADDRESS:7051 VALMONT STREETTELEPHONE:
(818) 352-4469
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:96CENSUS: 62DATE:
03/15/2022
UNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Ani NicholasTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Reporting Requirements – facility failed to report to the Department an alleged incident that occurred on 11/10/21
INVESTIGATION FINDINGS:
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On 03/15/2022, Licensing Program Analyst (LPA) Liana Stepanyan, conducted a subsequent complaint investigation for the purpose of delivering the findings for the above allegation. Upon arrival, LPA was greeted by Ani Nicholas. LPA observed 62 children under care and supervision with 13 staff members.

The investigation of the above allegation consisted of record review and staff interview. On 11/12/21 facility was made aware of the alleged incident that occurred on 11/10/21, however the incident was not report to the department within 24 hours and a written report within 7 calendar days.
The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.
The facility was cited a Type B violation. See complaint investigation report LIC 9099D for deficiency cited.

An exit interview was conducted, a copy of this report, notice of site visit and appeal rights were provided to the licensee along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Liana Stepanyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
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 2
Control Number 12-CC-20211115150552
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: PINEWOOD AVENUE EARLY EDUCATION CENTER
FACILITY NUMBER: 191890442
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2022
Section Cited
CCR
101212
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Reporting Requirements: Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, 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. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. This requirement was not met as evidence by
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Director stated she will submit to the department no later than 03/29/22 an unusual incident report concerning the alleged incident that occurred on 11/10/21.
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Based on LPAs observations and interviews which were conducted and record review, it was determined that on 11/12/21 facility was made aware of the alleged incident that occurred on 11/10/21, however the incident was not report to the department within 24 hours and a written report within 7 calendar days. This is a type B deficiency that if not corrected poses a potential Health and Safety risk to children 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.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Liana Stepanyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
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