197417359-10-20-2023-58-CC-LHEZ-CWSSTZ-20231020141021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197417359
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:10:34 PM

Document Has Been Signed on 10/20/2023 02:10 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	GAULT ST. ELEMENTARY SCHOOL CSPP RM. 28		FACILITY NUMBER:	197417359
ADMINISTRATOR:	ALBION, WILLIAM B.		FACILITY TYPE:	850
ADDRESS:	17000 GAULT STREET		TELEPHONE:	(818) 343-1933
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	24	CENSUS: 9	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	ANTOINETTE BRUSCA, PRINCIPAL		TIME COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Lilia Hernandez and Joe Katrdzhyan conducted an unannounced annual inspection to the above facility on 10/20/2023. LPA arrived at the facility at 08:45AM, identified self and met with Antoinette Brusca, Principal who guided analyst on a tour of the facility. LPAs provided Principal with a copy of the LIC 125 Entrance Checklist to help facilitate the inspection. This is a preschool program which consists of 1 classroom; Room 28. Facility operation hours are Monday to Friday from 8:00 AM to 2:30 PM. All areas identified on the Facility Sketch were inspected. There were 9 children and 2 staff present when LPAs arrived. The facility was observed to be within the license capacity and limitations. Criminal record clearance was not reviewed. However, per condition of employment with the Los Angeles Unified School District, all individual’s present have obtained a criminal record clearance or criminal record exemption. The following was observed during the tour of the facility: Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Children in Room 28 have their own cubby to store their belongings. Mats and linens are provided for each child enrolled. Linens are washed weekly by school district. LPAs observed napping equipment stored in classroom in the location away from children’s activities. Napping equipment (mats) were observed to be stored in individual bags. --Page 1 of 4

SUPERVISOR'S NAME: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia Hernandez	TELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GAULT ST. ELEMENTARY SCHOOL CSPP RM. 28	FACILITY NUMBER: 197417359
	VISIT DATE: 10/20/2023

NARRATIVE

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Age-appropriate sinks and toilets were inspected for availability and good repair in the restrooms. Room 28 also has an additional sink for handwashing. General sanitation was observed.

Availability of indoor drinking water was observed in the classroom. Per principal, children bring their own water bottle daily and bottled water is available for children who need water refills.

Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Principal states that poisons are locked in the hopper room.

Carbon monoxide detectors were not observed in the facility.

All kitchen areas/food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin.

All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids or solid waste bags shall be discarded immediately after each meal.

LPAs observed trash can with solid waste located in the outdoor play area with no tight fitted lid. (photo taken)

Outdoor playground equipment is in a safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, slides, and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard. Availability of outdoor drinking water was observed.

LPAs advised that no children shall be left without the supervision of a teacher at any time.

All floors were observed to be clean and safe. All materials accessible to children were observed to be toxic-free. --Page 2 of 4

SUPERVISOR'S NAME: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia Hernandez	TELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GAULT ST. ELEMENTARY SCHOOL CSPP RM. 28	FACILITY NUMBER: 197417359
	VISIT DATE: 10/20/2023

NARRATIVE

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Per Principal, are no firearms stored on the premises. LPA's did not observe pools or bodies of water at the facility.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.
For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

LPAs verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Children’s Records were reviewed. Inspection of required forms was made and documented on the LIC 857. Children's roster was reviewed and is current. Sign-In and Sign-Out sheets were reviewed. Children present were signed in.

LPA also reviewed staff records. The review of Staff records was documented on the LIC 859. Staff present did not have proof of the AB 1207 Mandated Reporter Training certificate on file. Staff present did not have proof of measles, pertussis, and influenza. All staff have been given on the-job training sanitation principles, housekeeping, including universal health precautions.

There is at least one person trained in CPR and Pediatric First Aid present during this inspection.

Menus are posted one month in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request. The facility provides breakfast, lunch, and snack to children. Food is prepared in the main elementary cafeteria.

Per principal, children eat lunch in the main elementary eating area.

LPAs did not observe a waiver on file regarding to use of the common eating area.
Principal was advised to submit a waiver request detailing the use of the common lunch eating area and how commingling with other children will be prevented. ---Page 3 of 4

SUPERVISOR'S NAME: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia Hernandez	TELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GAULT ST. ELEMENTARY SCHOOL CSPP RM. 28	FACILITY NUMBER: 197417359
	VISIT DATE: 10/20/2023

NARRATIVE

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Disaster drill logs was available, last earthquake drill was conducted on 10/19/2023. Last fire drill was conducted on 9/18/2023.

First Aid supplies were observed in the classroom in a cabinet. According to Principal, medication is only administered to a child when accompanied with a doctor's note and is stored in the office. The facility was observed to be equipped with an isolation area for any child who becomes ill and it is located in the nurse’s office.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Principal was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

The following deficiencies listed on the attached deficiencies page are being cited in accordance with California Code of Regulations Title 22.

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

Exit interview conducted and report was reviewed with Antoinette Brusca, principal. ---Page 4 of 4

SUPERVISOR'S NAME: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia Hernandez	TELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 10/20/2023 02:10 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GAULT ST. ELEMENTARY SCHOOL CSPP RM. 28	FACILITY NUMBER: 197417359
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.954

Licensure Requirements

Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in LPAs did not observe a carbon monoxide detector installed in the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Per Principal, carbon monoxide detector will be installed, photo of the correction will be emailed to LPA by the POC due date.

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in LPAs did not observe the LIC610 posted or readily available which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Per Principal, LIC 610 will be updated and a copy will be emailed to LPA by the POC due date.

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: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia Hernandez	TELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 10/20/2023 02:10 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GAULT ST. ELEMENTARY SCHOOL CSPP RM. 28	FACILITY NUMBER: 197417359
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in LPAs observed trash can with solid waste located in the outdoor play area with no tight fitted lid which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Per Principal, a trash can with a fitted lid will be placed in the outdoor play area and a photo of the correction will be emailed to the LPA by the POC date.

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 of 2 staff did not have certificates of completion for mandated reporter training on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Per Principal, website will be provided to staff, copy of certificate will emailed to LPA by POC due date.

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: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia Hernandez	TELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 10/20/2023 02:10 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GAULT ST. ELEMENTARY SCHOOL CSPP RM. 28	FACILITY NUMBER: 197417359
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2023

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 of 2 staff did not have immunization on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2023
	Plan of Correction
1 2 3 4	Per Principal, immunization records will be obtained, copies of documents will be emailed to LPA by POC due date.

Type B

Section Cited

CCR

101221(a)

Child's Records

(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center. 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 2 of 5 children records reviewed were incomplete. Child 2 - Missing - TB, LIC701 Child 3 - Missing - Emergency card (LIC700, LIC627) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Per Principal, documents will be obtained and copies will be submitted to LPA by POC due date.

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: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia Hernandez	TELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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