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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197404132
Report Date: 03/19/2021
Date Signed: 03/29/2021 08:55:06 AM

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:PACE - WEST BOULEVARDFACILITY NUMBER:
197404132
ADMINISTRATOR:SILVA DE LA ROSAFACILITY TYPE:
850
ADDRESS:1809 WEST BLVD.TELEPHONE:
(323) 954-8099
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:68CENSUS: 12DATE:
03/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ruzanna DavtianTIME COMPLETED:
10:45 AM
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On 03/19/2021 at 9:00am, Licensing Program Analyst (LPA) Lillian Casillas conducted a Case Management- Incident Tele-Inspection for the purpose of following up on the Unusual Incident Report (UIR) submitted on 02/19/2021. LPA met with Ruzanna Davtian, Regional Site Director, and discussed the purpose of the visit.

According to the UIR, on 02/18/2021 at approximately 11:40am, Child #1 (C1) showed Staff #1 (S1) a small cut on his finger. When S1 asked C1 where he cut his finger, C1 pointed to broken glass on the carpet. S1 cleaned C1’s wound, called C1’s mother and gave her an Ouchie Report. Upon further inspection, S1 stated that the broken glass on the carpet was residue from a light bulb that maintenance staff replaced.

During the investigation, LPA conducted interviews with the Regional Site Director and 4 staff, toured the inside of the classroom, and reviewed the facility's internal Incident Report, Unusual Incident Follow-Up form, as well as the facility's Daily Classroom & Exterior Review form for the week of 02/15-02/19/2021. During the tele-inspection, LPA observed the carpet described in the UIR to be 2 large rugs.

Based on interviews, observation, and record review, the incident was not deemed a result of a Title 22 violation. LPA issued a (LIC 9102) Advisory Notes - Technical Assistance to the Regional Site Director to offer consultation on a safe and clean indoor environment pursuant to Title 22 Regulation 101238.3 (b).

An exit interview was conducted on 03/19/2021 at 10:45am and a copy of this report along with the Notice of Site Visit were provided to Ruzanna Davtian, Regional Site Director. LPA Casillas requested an email reply from the Regional Site Director in lieu of a signature.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021
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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