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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416599
Report Date: 09/22/2022
Date Signed: 09/22/2022 12:20:30 PM


Document Has Been Signed on 09/22/2022 12:20 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:WALNUT PARK ELEMENTARY SCHOOL LAUPFACILITY NUMBER:
197416599
ADMINISTRATOR:SARAHI LUNAFACILITY TYPE:
850
ADDRESS:2642 OLIVE STREET RM.B1 & B2TELEPHONE:
(323) 588-3145
CITY:HUNTINGTON PARKSTATE: CAZIP CODE:
90255
CAPACITY:42CENSUS: 22DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Saraid Luna, Facility RepresentativeTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 9/22/22 at 8:45AM. LPA met with Saraid Luna, Facility Representative (FR)..

There were 22 children and five staff present when LPA arrived. This is a preschool program, operating an AM program 8:00AM -11:00AM and a PM program, 12:00PM-3:00PM. Facility is on the campus of Walnut Park Elementary School in Rooms B-1 and B-2.

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 Classrooms Room B-1 and B-2. Classrooms have furniture 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 water bottles brought from home and water bottles provided by facility. LPA observed extra water bottles on hand in the classroom. Room B-1 also has an operable water fountain. Children have cubbies to store personal belongings separate from each other. Staff's personal belongings are stored in a locked cabinet in both classrooms, inaccessible to children. Children do not nap at facility due to part time schedules.

LPA toured the children’s restroom. LPA observed a waiver on file for shared restroom. Restrooms are located around the corner to the right of the preschool outdoor space. Preschool does share the restroom with other elementary children. Per classroom staff, preschool is always supervised while in the restroom and they do not co mingle with other programs. 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: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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: WALNUT PARK ELEMENTARY SCHOOL LAUP
FACILITY NUMBER: 197416599
VISIT DATE: 09/22/2022
NARRATIVE
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LPA toured the outdoor play area. Facility has a waiver on file for shared outdoor space. Preschool shares yard with Transitional Kindergarten (TK). Since yard is shared, preschool takes toys and material outside from the classroom as needed. Daily schedule was observed to reflect staggered outdoor times. Per classroom staff, preschool children do not co-mingle with TK. Shade was observed in the outdoor area. Water bottles are taken outdoors for children to drink freely. Water fountain are also available outdoors. LPA reminded FR that trash cans for solid waste need tight fitting lids.

LPA reviewed Sign In/Out sheets located in the classrooms. LPA observed that all AM children were signed in with the date and full signature of guardian. LPA advised classroom staff to remind parents to add the time of drop off.

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. LPA observed all required documents posted in each classroom entrance.

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 9/12/22. All documents were observed.

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. LPA observed five out of five children's files were missing LIC995 and LIC613A.

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 four out six staff are missing Mandated Reporter and Immunization records on file.

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 ----------------------PAGE 2
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: WALNUT PARK ELEMENTARY SCHOOL LAUP
FACILITY NUMBER: 197416599
VISIT DATE: 09/22/2022
NARRATIVE
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solid waste. Cleaning supplies are stored separate from the food. Carbon monoxide detector was discussed with FR.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

LPA provided FR with Lead Flyer, LIC 9108, LIC 9052, LIC995 and LIC613A.

LPA observed that facility is still 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.

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

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: WALNUT PARK ELEMENTARY SCHOOL LAUP
FACILITY NUMBER: 197416599
VISIT DATE: 09/22/2022
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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, Saraid Luna.



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

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/22/2022 12:20 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: WALNUT PARK ELEMENTARY SCHOOL LAUP
FACILITY NUMBER: 197416599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 4 out of 4 staff files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Facility Rep states that she will remind staff to bring in records and give them a two week due date and email certificates to LPA by POC date 10/21/22
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 4 out of 4 staff files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Facility Rep states that she will remind staff and give a two will due date to complete and email certificates to LPA by POC date 10/21/22

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: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 09/22/2022 12:20 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: WALNUT PARK ELEMENTARY SCHOOL LAUP
FACILITY NUMBER: 197416599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 5 out 5 children's files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Facility Rep states that she will distribute form to current families and add form to yearly checklist for future enrollment. FR will email signed copied to LPA by POC date 10/21/22
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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2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out 5 children's files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
1
2
3
4
Facility Rep states that she will distribute form to current families and add form to yearly checklist for future enrollment. FR will email signed copied to LPA by POC date 10/21/22

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: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6