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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416054
Report Date: 11/19/2020
Date Signed: 11/19/2020 01:37:47 PM

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:KIDS PARK NORTHRIDGE (SA)FACILITY NUMBER:
197416054
ADMINISTRATOR:ROSS, DAVIDAFACILITY TYPE:
840
ADDRESS:9056 TAMPA AVENUETELEPHONE:
(818) 998-5437
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:25CENSUS: 15DATE:
11/19/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jamie ChastainTIME COMPLETED:
01:20 PM
NARRATIVE
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Margarit Sislyan, Licensing Program Analyst (LPA) conducted a tele-visit to follow up with the incident occurred on 12/28/2019.

Licensee failed to report the incident to CCLD. The incident was reported to CCLD as a complaint with the following allegations: Staff did not prevent inappropriate interactions between children resulting in injury; Staff did not seek medical attention for child in a timely manner.

Complaint investigation was conducted. Based on investigation there were no violations.



Licensee was cited with type B citation for not reporting the incident.

Exit interview.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit SislyanTELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: KIDS PARK NORTHRIDGE (SA)
FACILITY NUMBER: 197416054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2020
Section Cited

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101212 Reporting Requirements
Each licensee or applicant shall furnish to the Department reports as required by the Department any injury to any child that requires medical treatment. This requirement is not met as evidenced by:
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Based on observation Licensee failed to report the incident which required medical treatment.
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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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit SislyanTELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2