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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192002562
Report Date: 10/11/2023
Date Signed: 10/11/2023 01:17:57 PM


Document Has Been Signed on 10/11/2023 01:17 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:ANGELINA PRESCHOOLFACILITY NUMBER:
192002562
ADMINISTRATOR:PEREZ, ADRIANAFACILITY TYPE:
850
ADDRESS:1336 ANGELINA STREET #108TELEPHONE:
(213) 481-0227
CITY:LOS ANGELESSTATE: CAZIP CODE:
90026
CAPACITY:73CENSUS: 46DATE:
10/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Adriana Perez, DirectorTIME COMPLETED:
01:30 PM
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On October 11, 2023, Licensing Program Analysts (LPAs) Monique Ayala and Kruz Long conducted an unannounced case management inspection. A COVID-19 risk assessment was assessed prior to entering the facility. The purpose of the inspection is to follow up on an incident that occurred on 10/03/2023 and was reported to the department on 10/04/2023; the report was reported timely. LPAs met with Director, Adriana Perez who guided LPAs on a tour of the facility. LPAs observed 46 children in care.

Brief Summary: Child #1 (C1) was sliding down the slide, began crying, staff #1 (S1) asked what happened and C1 was holding her wrist. C1 told Staff #2 (S2), when she came down the slide she fell on the matting area and her hand began to hurt. C1 had a sprain on her wrist and got cast. Nothing broken.

During the inspection LPAs interviewed C2-C3, LPAs were unable to interview C1, as C1 did not want to be interviewed, LPAs interviewed S1-S3, obtained a copy of the facility roster and obtained a copy of C1's internal incident report.

Based on interviews conducted the facility is not being cited any deficiencies, but it being given a Technical Violation for Title 22 Regulation 101229(a)(1), Responsibility for Providing Care and Supervision. C2 and C3 did not observe the incident. S1 stated that she was right next to the slide when the incident occurred but had turned to assist another child. S2 stated she was 10 feet away from the slide but was supervising the children on the climbing structure. S2 stated that C1's father arrived to pick up C1 when C1 was taken into the office. LPAs observed the play structure to be in good repair and observed the cushion material to be in good repair. The facility had 25 children outside during the time of the incident with 5 staff members. Per director, C1's mother stated that C1 disclosed no other child had pushed or pulled C1; C1 had slid down the slide alone.

An exit interview was conducted and copy of this report was provided to the director along with Notice of Site Visit. The 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: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
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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