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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416900
Report Date: 08/18/2022
Date Signed: 08/18/2022 12:40:05 PM


Document Has Been Signed on 08/18/2022 12:40 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:107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD STARTFACILITY NUMBER:
197416900
ADMINISTRATOR:ALETA WILLIAMSFACILITY TYPE:
850
ADDRESS:146 EAST 107TH. STREET ROOM K4TELEPHONE:
(323) 756-8137
CITY:LOS ANGELESSTATE: CAZIP CODE:
90003
CAPACITY:22CENSUS: 12DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Monica Williams, Facility RepresenativesTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 3/2/22 at 10:30 AM. LPA met with Monica Williams, Facility Representative (FR) who guided analysts on a tour of the facility.

There were 12 children and three staff present when LPA arrived. This is a full day preschool program, operating 8:00AM to 2:19PM. Facility is on the campus of 107th St Elementary in Room K-4. 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 K-4. 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 by via water bottles brought from home and provided by facility. LPA observed extra water bottles on hand in the classroom. Water fountains in the classrooms are not being used due to COVID-19 precautions. Children have cubbies to store personal belongings. LPA reminded FR that all outlets in the classroom need to be covered. LPA was informed that children are not napping/resting at the facility. LPA informed FR that because this is a full day program, nap/rest times must be added to the daily schedule and children need to be given the opportunity to nap or rest without distraction from other activities. Per FR there are currently no children with medication. Carbon monoxide detector is wired with the facility smoke/fire alarm.

LPA toured the children’s restrooms. LPA observed a waiver on file for shared restroom. Preschool shares restroom with a Transitional Kindergarten class (ETK). LPA reminded classroom teachers that the ETK program cannot be in the classroom 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: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900
VISIT DATE: 08/18/2022
NARRATIVE
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LPA toured the outdoor play area. Outdoor area was observed to have age appropriate toys and material for children, free of loose, sharp, and/or pointed parts. LPA observed required cushioning under climbing structure to absorb fall. Shade was observed in the outdoor area and water was observed to be readily available via water bottles. Outdoor water fountains are currently not used. Outdoor area is also used by the ETK program. Per FR, children are not out at the same time. Waiver on file for staggered play outdoors.

LPA reviewed Sign In/Out sheets. LPA observed that sign in sheet did not have sign in/out times for 12 out 12 children for Monday-Thursday. LPA reminded teaching staff that parents must include the time when the drop off the child and the time when they pick up the child for safety reasons.

LPA observed required posted documentation which included, Facility License, Publication (PUB) 393- Notification of Parent Rights, PUB 269- Child Passenger Restraint System, Licensing Form LIC 613A- Notification of Personal Rights and Lunch/Snack Menu in the preschool classroom. Facility records were reviewed for 9148- Earthquake Preparedness form and (LIC) 610- Facility Disaster Plan. Disaster drill was last drill conducted in May 2022 before summer vacation. Facility has just reopened 8/15/22 with disaster drill scheduled for mid September.

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. Two out of four files were missing Physician's report. 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 3 out of 3 staff are missing Mandated Reporter training, Immunization records and TB. LPA did not observe a current CPR and First aid certificate for at least one staff in the preschool program. LIC 9108 and LIC9052 were discussed.

At LPA observed the kitchen located on the elementary campus. Facility provides AM snack, Lunch and PM snack. Food is not cooked at the facility. Prepackaged food is delivered daily. Extra food is stored in the kitchen. Kitchen was observed to be clean, free of litter, insects and rodents. LPA informed FR that all trash cans in the classroom, outdoors and in the kitchen need tight fitting lids for solid waste. Cleaning supplies are stored separate from the food. ----------------------PAGE 2
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 2 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: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900
VISIT DATE: 08/18/2022
NARRATIVE
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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, Monica Williams.


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

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/18/2022 12:40 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: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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. Trash cans in the classroom and on the playground were observed to have solid waste without lids, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Facility Representative (FR) agrees to speak with custodial staff regarding trash cans and they will have lids by the end of next week. FR will email pictures of trash cans with lids by 9/16/22.
Type B
Section Cited
CCR
101230(b)
Activities/Napping
(b) All children shall be given an opportunity to nap or rest without distraction or disturbance from other activities at the center.

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. Children are not being given an opportunity to nap or rest, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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FR agrees to put a plan in place to add a nap time to the daily activities. Children will begin napping on 8/29/22. FR will send a copy of the new daily schedule with nap time added by 8/29/22.

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: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 08/18/2022 12:40 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: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022

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/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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FR agrees to obtain immunization records from staff, add it to their files and email copies to LPA by 9/16/22 .
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/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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FR agrees have staff take mandated reporter training and email completed certificates by 9/16/22.
www.mandatedreporterca.com
Take the general section and Child Care Providers section

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: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 08/18/2022 12:40 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: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022

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. FR was not able to provide a current CPR/1st aid certificare for a staff member in the Preschool program, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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FR will ask teaching staff to provide current certificates and email LPA proof by 9/16/22
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

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 for 12 out 12 children on the sign in/out sheet, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2022
Plan of Correction
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Starting today teaching staff will require the parents to add the time in and time out to the sign in sheets. FR will email LPA a copy of the sign in sheet by 8/19.

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: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6