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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197413853
Report Date: 06/03/2022
Date Signed: 06/03/2022 12:16:20 PM


Document Has Been Signed on 06/03/2022 12:16 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:SARA COUGLIN ELEMENTARY SCHOOL CSPPFACILITY NUMBER:
197413853
ADMINISTRATOR:FOSCHETTI, GIOVANNAFACILITY TYPE:
850
ADDRESS:11035 BORDEN STREET RM 1&2TELEPHONE:
(818) 686-6428
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY:48CENSUS: 16DATE:
06/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Leticia Sanchez, Principal TIME COMPLETED:
12:20 PM
NARRATIVE
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On 6/03/2022 at 8:15 am Licensing Program Analyst (LPA) Deborah Lowe, conducted an unannounced Annual Required Inspection for the preschool license. Facility is located on a Los Angeles Unified School District (LAUSD) campus. LPA met with Maria Canales, School Administrative Assistant, LPA identified reason for visit. At 8:25 am LPA Lowe arrived at preschool classrooms located in rooms #1 & 2, met with classroom teachers and toured the facility indoors and outdoors. Days and hours of operation are Monday – Friday 8:00 am – 11:00 am and 11:30 am – 2:30 pm.

LPA Lowe observed 16 children under direct supervision of 2 qualified teachers and 2 teacher assistants.

There is no swimming pool or other bodies of water on the premises. At 8:33 am LPA observed 1 disinfectant spray bottle, disinfectant wipes accessible to the children on the floor of room 2. At 8:38 am LPA observed dry erase cleaning bottle under the wipe on board and shaving cream and bottle of starch under the classroom sink in unlocked cabinet. 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 cleaning solutions, shaving cream, and starch inaccessible to children during visit.

At 8:33 am LPA observed a container of Children's Vicks Vapo Rub - in an unsecured cart accessible to children in room 2. LPA advised per 101226(e)(1)(A) (A) Medications shall be kept in a safe place inaccessible to children.

Staff made the container of Vicks Vapo Rub inaccessible to children during visit.

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

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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: SARA COUGLIN ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197413853
VISIT DATE: 06/03/2022
NARRATIVE
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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. At 9:05 am LPA observed 2 solid waste storage container with trash in container located on the playground in need of a lid. LPA advised Per CCR 101239(f)(1) (1) All containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof. At 9:43 am LPA observed Schools Plant Manager place tight fitting lids on outdoor solid waste storage containers.

Drinking water is available both indoors and outdoors.

Areas around high climbing equipment and slides have cushioning material to absorb falls. The facility is free of flies, insects and rodents.

At 9:46 am Assistant Principal advised LPA Lowe facility does not have a carbon monoxide detector. LPA advised per HSC 1596.954 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.

Capacity and limitations as specified on the license are being maintained. LPA observed teachers current CPR and Pediatric First Aid certificate posted in the classroom. LPA advised the name of the child care center director or fully-qualified teacher(s) designated to act in the director’s absence shall be been reported to the Department. Due to COVID protocols the teacher stated facility is using Daily Pass app to sign children in/ out. LPA observed use of the Daily Pass upon arrival to facility.

LPA reviewed a sample of children’s files and observed 9 out of 10 files to be complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment.

At 11:14 am pm LPA reviewed 3 out of 10 children’s files reviewed to be missing verification of Personal Rights, LIC613A and Parent’s Rights, LIC995. 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]). LPA advised per CCR 101218.1(e) (e)At the time of acceptance of each child into care and for all children in care on August 7, 2002, the licensee shall give each parent or authorized representative a copy of the Notification of Parents' Rights (LIC 995 [8/02]) and the LIC 995E, Caregiver Background Check Process form.

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

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
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: SARA COUGLIN ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197413853
VISIT DATE: 06/03/2022
NARRATIVE
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Due to staff files are kept at LAUSD district office LPA did not review staff files during this visit. LPA Lowe did observe teachers’ qualifications during visit. Menus are posted in classroom and in entry way to front office.

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.



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 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 deficiency is 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, Leticia Sanchez, Principal.

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

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 06/03/2022 12:16 PM - 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: SARA COUGLIN ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197413853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022

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: 06/10/2022
Plan of Correction
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Assistant Principal stated they verified with the Schools CPM that a Carbon Monoxide Detector will be provided to the facility, facility will take a picture and identified were placed via email to LPA Lowe on or before 6/10/2022.
Type B
Section Cited
CCR
101226(e)(1)(A)
Health-Related Services
(e) In centers where the licensee chooses to handle medications: (1) All prescription and nonprescription medications shall be centrally stored in accordance with the requirements specified below: (A) Medications shall be kept in a safe place inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed 1 container of non prescription Vicks Vapo Rub in the classroom on a cart accessible to children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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On 6/03/2022 Teachers in classroom corrected during visit. LPA observed teacher place non prescrition Vicks Vapo Rub in a cabinet on a high shelf making inaccessible to children.

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: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 06/03/2022 12:16 PM - 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: SARA COUGLIN ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197413853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, the licensee did not comply with the section cited above in LPA observed cleaning solutions on floor of room 2 and cleaning solutions under sink and under wipe board in room 1 accessible to children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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On 6/03/2022 LPA observed teachers in each room remove cleaning solutions and placing on high shelf in a cabinet making cleaning solutions inaccessible to children.
Type B
Section Cited
CCR
101239(f)(1)
Fixtures, Furniture, Equipment and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed 2 solid waste containers without tight fitting lids located on the preschool playground which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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On 6/03/2022 LPA observed schools Plant Manager place tight fitting lids on solid waste containers located on the preschool playground.

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: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 06/03/2022 12:16 PM - 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: SARA COUGLIN ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197413853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

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 1out of 10 children's files reviewed are in need of a signed consent for emergency medical treatment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Facility will obtain written consent for medical treatment and email to LPA Lowe on or before 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 3 out of 10 children's files reviewed were found in need of signed acknowlegment of Personal Rights form (LIC613A) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Facility will obtain signed LIC 613A and email to LPA Lowe on or before 6/10/2022.

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: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
LIC809 (FAS) - (06/04)
Page: 6 of 9