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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197404132
Report Date: 08/26/2021
Date Signed: 08/26/2021 10:14:45 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: 41DATE:
08/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marlia FigueroaTIME COMPLETED:
10:30 AM
NARRATIVE
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On 8/26/2021 at 9:00AM, Licensing Program Analyst (LPA) Lillian Casillas arrived at the facility to conduct an unannounced Case Management – Incident inspection for the purpose of following up on an Unusual Incident Report (UIR) submitted on 8/18/2021. LPA met with Lead Teacher, Marlia Figueroa, and discussed the purpose of the visit.

According to the UIR, on 8/16/2021 at approximately 8:40AM, Child #1 (C1) was stung in the back of the head, back of the neck, and right index finger by yellow jackets while C1 played in the outdoor playhouse. Staff 1 checked C1’s stings and applied a cold pack on affected areas. Pest Control was scheduled to visit on 8/17/2021 and the area was closed off.



During the investigation, LPA interviewed the Lead Teacher, toured the inside and outside of the facility, inspected the playhouse, and reviewed the facility's Daily Classroom & Exterior Review forms for the weeks of 8/23-8/27/2021 and 8/16-8/20/2021. LPA also reviewed the facility history, which revealed that Child 2 and Child 3 were stung by hornets while they played in the outdoor playhouse at the facility on 6/14/2021.

Based on interview, observation, and record review, a Type B deficiency was cited during today’s inspection (see LIC 809-D).

An exit interview was conducted and a copy of this report (LIC 809), LIC 809-D, Notice of Site Visit, and Appeal Rights were provided to Lead Teacher.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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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: PACE - WEST BOULEVARD
FACILITY NUMBER: 197404132
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2021
Section Cited

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101238 Buildings and Grounds (a) The child care center shall be clean, safe, sanitary and in good repair... (1) The licensee shall take measures to keep the center free of flies, other insects, and rodents.
This requirement is not met as evidenced by:
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Based on interview, observation, and record review, the facility did not ensure that the outdoor playhouse is free of wasp and hornet nests, which poses a potential health, safety, or personal rights risk to children in care.
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Exterior Review form and provide proof by
8/27/2021. S2 was not present during today's inspection. S2 agrees to call/email LPA to confirm POCs by EOD 8/27/2021.

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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: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Lillian J CasillasTELEPHONE: (424) 301-3097
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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