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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197412885
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:05:22 PM

Document Has Been Signed on 03/28/2022 04:05 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:ST. SEBASTIAN PRE-KFACILITY NUMBER:
197412885
ADMINISTRATOR:MARISA FUENTESFACILITY TYPE:
850
ADDRESS:1430 FEDERAL AVENUETELEPHONE:
(310) 473-3337
CITY:LOS ANGELESSTATE: CAZIP CODE:
90025
CAPACITY: 60TOTAL ENROLLED CHILDREN: 30CENSUS: 16DATE:
03/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Marisa Fuentes, Director TIME COMPLETED:
04:10 PM
NARRATIVE
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On 03/28/2022 at 1:05 PM, Licensing Program Analyst (LPA) Denise Miranda conducted an unannounced case management inspection at St Sebastian Preschool, located at 1430 Federal Ave, Los Angeles, CA 90025 for the purpose of following up on the unusual incident that was self-reported by the facility. The El Segundo Child Care Regional Office received the report on 03/14/2022. LPA met with Director Marisa Fuentes that guided LPA indoor and outdoor.
According to the incident report, on 03/04/2022, child#1 was playing at the playground and fell out from the big slide. Child#1 scraped her forehead, arm and finger. Ice pack was applied, and parents were contacted immediately.
Parents of the child took to the hospital and a cast was placed on child’s right arm due a fracture.
During this inspection, LPA Miranda, conducted interviews and inspection at the outdoor space. LPA observed that the playground has two slides (small and large). Per Director when the incident happened the surface it was covered with sand. Director removed the sand and the surface has rubber mulch at the playground area and some area needs repair.
LPA observed when Director placed a yellow tape at the playground structure, making this area inaccessible to the children in care. A declaration was obtained from Director regarding playground structure and age appropriate.
Based on the available information, it appears that the incident was the result of a Title 22 violation for Fixtures, Furniture, Equipment and Supplies. acility was cited a Type B violation today, 03/28/2022 (See LIC 809-D for deficiency cited.)

An exit interview was conducted and a copy of this report, appeal rights and Notice of Site Visit was provided to Marisa Fuentes, Director.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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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Document Has Been Signed on 03/28/2022 04:05 PM - It Cannot Be Edited


Created By: Denise Miranda On 03/28/2022 at 03:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ST. SEBASTIAN PRE-K
FACILITY NUMBER: 197412885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2022
Section Cited
CCR
101239(m)

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(m) All play equipment and materials used by children shall be age-appropriate. During inspection, LPA observed that Playgroung does not have age appropriate label or manual available.
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LPA observed Director, to placed a yellow tape at the PLayground area and making inacessible to the chidlren in care. Director, provided a declaration regarding playground.
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Director agreed to have playground inspector to determine the age appropriate of the equipment and a label shall be place at the equip. Documents will be provide via email to LPA Miranda no later than 4/12/22

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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022


LIC809 (FAS) - (06/04)
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