197402791-6-23-2022-30-CC-DWHE-CFNR5J-20220623124313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197402791
Report Date: 06/23/2022
Date Signed: 06/23/2022 12:43:27 PM

Document Has Been Signed on 06/23/2022 12:43 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	EVERGREEN COMMUNITY SCHOOL		FACILITY NUMBER:	197402791
ADMINISTRATOR:	OBRIEN KAITLIN		FACILITY TYPE:	850
ADDRESS:	2800 COLORADO		TELEPHONE:	(310) 453-6255
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	56	CENSUS: 0	DATE:	06/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:51 AM
MET WITH:	Kaitlyn OBrien		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/23/2022 Licensing Program Analyst (LPA) XXX, conducted an unannounced Annual Required Inspection for the preschool license. LPA met with Director Kaitlin Obrien and toured the facility indoors and outdoors. Days and hours of operation are Monday- Friday 9:00a.m. to 1:45p.m. at the time of the inspection there were no children in care. The school consist of three classrooms. There is a total of three classrooms. Outdoor equipment was inspected for cushioning material, age appropriateness and good repair. Required shaded areas, Age appropriate toys were observed. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible. All poisons are kept in a locked storage area. No poisons were observed during the inspection.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris Whitmore	TELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: EVERGREEN COMMUNITY SCHOOL	FACILITY NUMBER: 197402791
	VISIT DATE: 06/23/2022

NARRATIVE

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Furniture and equipment are in good condition, free of sharp, loose or pointed parts. Playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All toilets and handwashing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. All kitchen, food preparation and storage areas are clean, free of litter/rubbish and free of rodents/vermin. All foods/beverages capable of rapid spoiling are stored in covered containers at 45 degrees F or less. Solid waste storage containers have tight-fitting covers and are in good repair. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available for the children in each classroom. All materials and surfaces accessible to children are toxic free. The facility is free of flies, insects and rodents. The children's lunch is catered by a local restaurant and delivered to the school.

Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. Prior to working or volunteering in a licensed childcare facility, all individuals subject to a criminal record review have received a criminal record clearance or exemption. No individuals excluded by the Department are allowed to be present. Capacity and limitations as specified on the license are being maintained. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility or at offsite activities. The name of the childcare center director or fully qualified teacher(s) designated to act in the director’s absence has been reported to the Department. LPA reviewed a sample of 5children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child. LPA reviewed a sample of staff 7 files and observed files were complete with documentation of meeting qualification requirements, immunization records for influenza, pertussis and measles and current documentation of completed mandated reporter training. Menus are posted and online where an authorized representative can view them.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris Whitmore	TELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: EVERGREEN COMMUNITY SCHOOL	FACILITY NUMBER: 197402791
	VISIT DATE: 06/23/2022

NARRATIVE

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Incidental Medical Services (IMS) are not currently being provided. Only in an emergency Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris Whitmore	TELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC809 (FAS) - (06/04)

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