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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416902
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:32:48 PM


Document Has Been Signed on 06/02/2022 12:32 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:99TH STREET ELEMENTARY SCHOOL CSPP/HEAD STARTFACILITY NUMBER:
197416902
ADMINISTRATOR:MARISSA BORDONFACILITY TYPE:
850
ADDRESS:9900 S.WADSWORTH AVE.RMS 12,13TELEPHONE:
(323) 564-2677
CITY:LOS ANGELESSTATE: CAZIP CODE:
90002
CAPACITY:24CENSUS: 0DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Marissa Bordon, Facility RepresentativeTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 6/2/22 at 9:20AM. LPA was initially met by Angela Killens, Vice Principal of the elementary school who informed that Marissa Bordon Facility Representative (FR) was conducting and assembly and would meet me soon. LPA was taken to the Preschool classroom and conducted inspection.

This is a preschool program that operates two sessions: AM, Monday - Friday from 8:00AM-11:00AM and PM, Monday - Friday, 12:00PM -3-00PM. Facility will be closed for Summer vacation from 6/10/22-8/15/22. LPA was informed that all children were sent home due to a COVID case. There were no children or staff present when LPA arrived. LPA discussed unusual incident reporting.

LPA toured Classroom #33. Classroom had furniture in good condition, free of loose, sharp and/or pointed parts. The floors and surfaces in the classroom were clean and safe. Rugs were observed to be flat on the ground to avoid tripping hazards. LPA observed disinfectant and air freshener under the children's sink with a broken child lock. Due to there being no children in care this is a potential hazard to children. Water is made readily available via water bottles provided by facility. LPA observed extra water bottles in storage. Per FR there are no children currently taking medication. Children have hooks to store personal belongings separate from each other. Children do not nap at facility due to program time. LPA toured the children’s restroom. Restroom was observed to be safe and sanitary with operable sink and toilet. There is a waiver on file for shared restroom space.

LPA toured outdoor play area. Preschool use the front 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.

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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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 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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902
VISIT DATE: 06/02/2022
NARRATIVE
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LPA observed that two out of three staff are missing proof of immunization and all staff are missing Mandated Reporter training certificate. Items were discus.

New Car Seat Law poster, Copy of blank Unusual Incident form, LIC 624 and Lead Flyer was provided.

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 Marissa Bordon.

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

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902
VISIT DATE: 06/02/2022
NARRATIVE
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Shade was observed throughout the outdoor area. Water bottles are taken outdoors. LPA observed used masks, used napkins, broken spoons and plastic wrappers on the ground in both yard. LPA also observed open individual milk cartons on the bench in the front yard. Due to no children being in care, this is potential hazard. Per FR, there are no weapons or firearms stored at the facility and there is no smoking allowed on the premises.

LPA discussed required posted documentation for the parent board, which included, Facility License, Outdoor and Restroom Waiver, Publication (PUB) 393- Notification of Parent Rights, Licensing Form (LIC) 610- Facility Disaster Plan, PUB 269- Child Passenger Restraint System, LIC 613A- Notification of Personal Rights and Lunch/Snack Menu.

Facility records were discussed which included, LIC 9040- Facility Roster and 9148- Earthquake Preparedness form. Daily schedules and Disaster drill log, last drill conducted on 5/23/22 were observed.

LPA toured the kitchen on site. Facility provides AM snack, PM snack and lunch. Food is not cooked at the facility. Prepackaged food is delivered daily. Extra food is sent home with the children. Kitchen was observed to be clean, free of litter, insects and rodents. Trash cans for solid waste have tight fitting lids. Cleaning supplies are stored separate from the food. Carbon monoxide detector is connected to the smoke/fire alarm system at the facility.

LPA reviewed Sign In/Out sheets located in the classroom. No children were sign in today. There were no children in care.

Children’s records were reviewed for Emergency Card, Immunization Records, Licensing Form (LIC) 627- Consent for Medical Treatment, LIC 995 Notification of Parents’ Rights, LIC 701- Physician’s Report, LIC 613A- Personal Rights, and signed Admissions Agreement. Documents were discussed.

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

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/02/2022 12:32 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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(a)
Disaster and Mass Casualty Plan
(a) Each licensee shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.

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, licensee did not ensure disaster plan was completed and posted, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Per Facility Rep she will have the form filled out for the new year with the new staff names because facility will be closing for summer break. FR will email form to LPA by 8/15/22
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

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, licensee did not ensure cleaning products were made inaccessible to children, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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Per Facility Rep she will remove the items from under the sink today and email picture to LPA by 6/3/22.

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: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 06/02/2022 12:32 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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022

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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2
3
4
Based on record review, the licensee did not comply with the section cited above in two out of two staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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4
Per Facility Rep, she will have staff bring in immunization records at the beginning of the new school year and email LPA proof by 8/15/22
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 two out of two staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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Per Facility Rep, she will have staff take tranining at the beginning of the new school year and email LPA proof by 8/15/22

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: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 06/02/2022 12:32 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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in six out of six files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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2
3
4
Per Facility Rep, she will add them to the enrollmnt packet for the next school year and provide LPA with an updated checklist by 8/15/22.
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in six out of six files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
1
2
3
4
Per Facility Rep, she will add them to the enrollment packet for the next school year and provide LPA with an updated checklist by 8/15/22.

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: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6