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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197405853
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:11:38 AM


Document Has Been Signed on 05/24/2022 11:11 AM - 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:STAGG STREET ELEMENTARY SCHOOLFACILITY NUMBER:
197405853
ADMINISTRATOR:BRANDON, PATRICIAFACILITY TYPE:
850
ADDRESS:7839 AMESTOY AVENUE, RM. 15TELEPHONE:
(818) 881-9850
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:23CENSUS: 8DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:Anna Valenzuela, Principal TIME COMPLETED:
11:20 AM
NARRATIVE
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On 5/24/3022 at 8:09 am Licensing Program Analyst (LPA) Deborah Lowe, conducted an unannounced Annual Required Inspection for the preschool license. LPA met with Staff #1, and toured the facility indoors and outdoors. Days and hours of operation are Monday – Friday 8:00 am – 11:00 am and 11:30 pm – 2:30 pm.

Facility is located on a Los Angeles Unified School District (LAUSD) campus. Childcare is located in room #15. LPA observed 8 children in care of 3 adult staff.

There is no swimming pool or other bodies of water on the premises. At 8:20 am LPA observed 1 Lysol spray bottle accessible to the children on a shelf near sink, 1 Lysol spray bottle under sink in unlocked cabinet and with cabinet containing cleaning solutions left open and unlocked. LPA advised per CCR 101238(g) (g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

Staff made the Lysol bottles inaccessible during visit and closed and locked cabinet containing cleaning solutions. No poisons were observed during the inspection.

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.

Elementary school has a cafeteria that handles all food preparation. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors.

LPA observed the facility to be free of flies, insects and rodents. Facility does not have a functioning carbon monoxide detector. LPA advised per HSC 1596.954 Every licensed child day care center shall have one or

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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: STAGG STREET ELEMENTARY SCHOOL
FACILITY NUMBER: 197405853
VISIT DATE: 05/24/2022
NARRATIVE
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more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

Capacity and limitations as specified on the license are being maintained. Health Office with Nurse on staff, all medications are stored in nurse office. First Aid supplies were observed. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility or at offsite activities. Facility uses “Daily Pass” as sign in/out system along with wellness check. All children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than 12 children in care.

LPA reviewed a sample of children’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 and immunization records. During review of children’s files LPA observed all files are in need of Parents’ Rights, Personal Rights, and and some need medical assessment. LPA advised per CCR 101223(b)(1) (1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]). Per 101220(a) (a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

Due to staff files are kept at LAUSD district office LPA did not review staff files during this visit. Menus are posted at least one week in advance where an authorized representative can view them.

Incidental Medical Services (IMS) are currently being provided. 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.


The following items were discussed:

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: STAGG STREET ELEMENTARY SCHOOL
FACILITY NUMBER: 197405853
VISIT DATE: 05/24/2022
NARRATIVE
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information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D) Licensee was provided a copy of their appeal rights.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the facility representative Anna Valenzuela.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/24/2022 11:11 AM - It Cannot Be Edited

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: STAGG STREET ELEMENTARY SCHOOL
FACILITY NUMBER: 197405853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in facility does not have a carbon monoxide detector which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Principal stated they will take a picture of the carbon monixide dectector and email to LPA as verification dectector.
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in cleaning solution left on shelf, in unlocked cabinet, and cabinet with cleaning solution open not locked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Staff corrected during visit by making all cleaning solutions inaccessible to children in care.

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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 05/24/2022 11:11 AM - It Cannot Be Edited

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: STAGG STREET ELEMENTARY SCHOOL
FACILITY NUMBER: 197405853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 8 out of 10 children's files reviewed did not have a medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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Office Manager will provide form to parent for doctor to complete. Note facility closes for summer on 6/10/2022
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 10 out of 10 children's files reviewed did not have signed Personal Rights form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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Office Manager will email LPA Lowe sign off pages of Personal Rights from each parent on or before end of business on 6/06/2022.

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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9