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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416729
Report Date: 01/21/2022
Date Signed: 01/21/2022 01:37:44 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
FACILITY NAME:MIDDLETON PRIMARY CENTER LAUPFACILITY NUMBER:
197416729
ADMINISTRATOR:FRANCES SANCHEZFACILITY TYPE:
850
ADDRESS:2410 ZOE AVENUE -ROOM 1TELEPHONE:
(323) 826-9533
CITY:HUNTINGTON PARKSTATE: CAZIP CODE:
90255
CAPACITY:24CENSUS: 4DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lorena AvalosTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 1/21/22 at 9:45AM. LPA met with Lorena Avalos, Facility Representative (FR) who guided analysts on a tour of the facility.

This facility is located on the campus of a primary center which also houses Kindergarten and first grade elementary students. Facility is located in Room one. There were four children and three staff present when LPA arrived. Facility capacity is in compliance with license capacity and Title Five ratio guidelines. 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.

At 10:00AM LPA observed required posted documentation which included, Facility License, Publication (PUB) 393- Notification of Parent Rights, Licensing Form (LIC) 610- Facility Disaster Plan, PUB 269- Child Passenger Restraint System, and LIC 613A- Notification of Parent’s Rights. Due to COVID-19 precautions and parents not entering the facility lunch/snack menus are posted online for parents to view.

At 10:10AM Facility records were reviewed for LIC 9040- Facility Roster, 9148- Earthquake Preparedness form, Daily schedule and Disaster drill log, last drill conducted on 12/15/21.

At 10:15AM LPA reviewed Sign In/Out sheets located in the classroom. Due to COVID-19 precautions, teachers are signing children in and out as they arrive and leave. All children present were signed in with date, time and full signature of representative.

At 10:30AM LPA toured Classroom one. LPA observed that the furniture is good condition and the floors are safe and sanitary. Per FR, the water fountain is located in the hallway, outside of the classroom. When ----------------------PAGE 1
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
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 5
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: MIDDLETON PRIMARY CENTER LAUP
FACILITY NUMBER: 197416729
VISIT DATE: 01/21/2022
NARRATIVE
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children want to drink, they ask the teacher so that they can supervise them. LPA observe water fountains in the hallway. Children have their own cubbies. Children do not nap a the facility because there are two half day programs.

At 10:50AM LPA observed required Carbon Monoxide detector tied to facility fire alarm system.

At 11:00AM LPA toured the children’s bathroom. LPA observed operable toilets and sinks. Bathroom was observed to be sanitary and free of hazards. Facility does have a waiver for shared use of the restroom with the elementary children. LPA did not observe commingling.

At 11:10am LPA toured the outdoor play area. LPA observed operable water fountains outdoors for children's use. The outdoor area has material and equipment for children to use. LPA observed shaded area over activity benches. The climbing structure has required padding under, that is kept in good condition. The facility has a waiver for shared outdoor space with the elementary students. Staggered outdoor schedule posted.

At 11:30 LPA toured the kitchen. Kitchen was sanitary, free of litter flies, vermin, and rodents. Kitchen had trash bins with tight fitting lids. Food is provided by the school district and is delivered prepackaged. Food is not made on site. LPA observed that cleaning supplies are stored separate room from food and there were not expired items.

Children’s records were reviewed at 11:40AM for Emergency Card with Consent for Medical Treatment, Immunization's Records, Licensing Form (LIC) 995 Notification of Parents’ Rights, LIC 701- Physician’s Report, LIC 613A- Personal Rights, and signed Admissions Agreement. LPA did not observe LIC 995 and LIC 613 in four out of four files.

Staff records were reviewed at 12:15PM for approved Pediatric First Aid and CPR certification for at least one staff member, LIC-501: Personnel Record, LIC 9052- Employee Rights, Proof of immunization's 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 three out of three staff did not have Mandated Reporter Training, CPR and First Aid certificates, immunization's, and teacher in the classroom had an expired permit on file. --------------------PAGE 2
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: MIDDLETON PRIMARY CENTER LAUP
FACILITY NUMBER: 197416729
VISIT DATE: 01/21/2022
NARRATIVE
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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 observed that FR is implementing COVID-19 precautions and procedures.

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.

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

Exit interview conducted and report was reviewed with the Facility Representative, Lorena Avalos.------------------PAGE 3

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

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: MIDDLETON PRIMARY CENTER LAUP
FACILITY NUMBER: 197416729
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2022

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 FR did not comply with the section cited above in four out of four files for S1, S2, and S3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2022
Plan of Correction
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Per FR, She will ask them to bring in immunization records, make a copy and keep it on file and email to LPA by 2/21/22
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 FR did not comply with the section cited above in four out of four files for S1, S2, and S3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2022
Plan of Correction
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Per FR, She will ensure they have taken the training and if not she will provide them time to take it during work and email certificates to LPA by 2/21/22
www.mandatedreporterca.com
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: 01/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: MIDDLETON PRIMARY CENTER LAUP
FACILITY NUMBER: 197416729
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2022

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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4
Based on record review, the FR did not comply with the section cited above in four out of four files for S1, S2, and S3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2022
Plan of Correction
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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: 01/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5