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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416587
Report Date: 09/08/2022
Date Signed: 09/12/2022 12:48:06 PM


Document Has Been Signed on 09/12/2022 12:48 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/12/2022 12:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

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 AMENDED REPORT
Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 9/8/22 at 10:40 AM (Date and time amended to reflect accurate above date and time). LPA met with Susanne Fisher, Facility Representative (FR) who guided analysts on a tour of the facility.

There were no children present when LPA arrived. LPA observed two staff on break in transitions to the PM program. This is a preschool program, operating an AM program 7:55AM -10:55PM and a PM program, 11:35-2:35PM. Facility is on the campus of San Miguel Elementary School in Room K-1. All individuals present have obtained a criminal record clearance or criminal record exemption as a condition of employment with the Los Angeles Unified School District.

LPA toured Classroom Room K-1. Classroom furniture was in good condition, free of loose, sharp and/or pointed parts. The floors and surfaces in the classrooms were clean and safe. Rugs were observed to be flat on the ground to avoid tripping hazards. Water is made readily available via an operable water fountain in the classroom. LPA observed extra water bottles on hand in the classroom. Children have a storage cart outside the classroom to store personal belongings. LPA advised that when staff is not on break and children are in the room, personal belonging such as purses and bags and hot drinks be stored inaccessible to children. LPA also advised that all cleaning products be kept in the same inaccessible area after use when children are present, this includes bleach and water spray and Clorox wipes.

LPA toured the children’s restroom. LPA observed a waiver on file for shared restroom. LPA observed that preschool have access to the restroom directly from their classroom. There is a door that leads to another classroom. LPA reminded FR that elementary students cannot be in the bathroom when the Preschool children are in there. Restrooms were observed to be safe and sanitary with operable sinks and toilets.
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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: SAN MIGUEL ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197416587
VISIT DATE: 09/08/2022
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LPA toured the outdoor play area. Facility has a waiver on file for shared outdoor space. Outdoor area was observed to have age appropriate toys and material for children, free of loose, sharp, and/or pointed parts. Shade was observed in the outdoor area. Operable water fountains were observed to be readily available. LPA reminded FR that trash cans for solid waste need tight fitting lids.

LPA reviewed Sign In/Out sheets located in the classroom. LPA observed that all AM children were signed in and out with the time, date and full signature of guardian.

LPA reviewed required posted documentation for, Facility License and Waivers, Publication (PUB) 393- Notification of Parent Rights, PUB 269- Child Passenger Restraint System, Licensing Form LIC 613A- Notification of Personal Rights, Daily Schedule and Lunch/Snack Menu in the preschool classroom. Documents were discussed and provided to FR during inspection.

Facility records were reviewed for 9148- Earthquake Preparedness form, LIC9040- Children's Roster and (LIC) 610- Facility Disaster Plan. Disaster drill was last drill conducted 8/31/22. Records were discussed and provided to FR during inspection.

Children’s records were reviewed for Emergency Card with signed medical consent, Immunization Records, LIC 995 Notification of Parents’ Rights, LIC 701- Physician’s Report, LIC 613A- Personal Rights, and signed Admissions Agreement. All documents were observed.

Staff records were reviewed at for approved Pediatric First Aid and CPR certification, LIC 9052- Employee Rights, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse, Transcripts or Permit and current Mandated Reporter Training Certificate. LPA observed that two out two staff are missing required documents and certificates.

At LPA observed the kitchen located on the elementary campus. Facility provides Breakfast and Lunch. Food is not cooked at the facility. Prepackaged food is delivered daily. Extra food is stored is discarded daily. Kitchen was observed to be clean, free of litter, insects and rodents. Trash cans in the kitchen have tight fitting lids for solid waste. Cleaning supplies are stored separate from the food. Carbon monoxide detector was discussed with FR. ----------------------PAGE 2
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: SAN MIGUEL ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197416587
VISIT DATE: 09/08/2022
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LPA observed that facility is implementing COVID-19 precautions and procedures as required by Los Angeles Unified School District and the Department of Public Health.

Incidental Medical Services (IMS):
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a plan for providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

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 living or working in the home, 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 licensed Family Child Care Home. 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.

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

Exit interview conducted and report was reviewed with the Facility Representatives, Susanne Fisher.


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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/08/2022 01:22 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: SAN MIGUEL ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197416587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

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. There no staff on site with a current CPR/First Aid certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2022
Plan of Correction
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Per FR, she will ask the classroom teacher if she has a current CPR/first aid certificate. If not she will add the school nurse who is at the facility 5 days a week to the Preschool licensee as a CPR certified staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4