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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417876
Report Date: 10/11/2022
Date Signed: 10/11/2022 06:06:16 PM


Document Has Been Signed on 10/11/2022 06:06 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:CLOVER STARFACILITY NUMBER:
197417876
ADMINISTRATOR:RASTIN, KATHERINEFACILITY TYPE:
840
ADDRESS:11020 CLOVER AVENUETELEPHONE:
(310) 678-6030
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:120CENSUS: 107DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Isaac Olmos- DirectorTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Keyona Scott, conducted an unannounced annual required inspection to the child care center on 10/11/2022. LPA met with Director, Isaac Olmos, at 1:05 PM. LPA was guided on a tour of the classrooms, restrooms, cafeteria areas and play yards utilized by the STAR program. At the time of LPAs arrival, there were no children present. All Adults present, working and/or volunteering have a criminal record clearance or exemption.

This is a school-age program that is located at Clover Avenue Elementary School. The program operates after school hours Monday, Wednesday, Thursday and Friday from 2:38 PM to 6:00 PM and Tuesday from 1:38 PM to 6:00 PM. The program serves children attending Clover Avenue Elementary School, grades T-K through fifth grade. The program utilizes four classrooms; rooms 22, 24 (STAR Main Office/classroom), 25 and 30. The children are divided into four classes by grade level, TK and Kindergarten (kinder), first (1st) grade, second (2nd) and third (3rd) grade, fourth (4th) and fifth (5th) grade.

LPA observed 1st grade class at 2:13 PM with 17 children to two (2) teachers; TK and kinder at 2:27 PM with 24 children to two (2) teachers; 4th and 5th grade at 2:24 PM with 26 children to two (2) teachers.

LPA did not observe proper teacher to children ratios. At 2:20 PM, LPA observed thirty (30) children to two (2) teachers in room 30, in which the 2nd and 3rd graders, were completing homework. LPA advised Director at 2:38 PM that the 2nd and 3rd grade classroom was out of ration and Director immediately resolved the issue and placed the classroom back into ratio. LPA conducted a recount on the census of the 2nd and 3rd grade classroom at 2:50 PM and observed the classroom in compliance with Department regulations and observed 28 children to two (2) teachers. LPA observed the 4th and 5th grade classroom at 2:54 with 28 children to two (2) teachers.
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SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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 11


Document Has Been Signed on 10/11/2022 06:06 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: CLOVER STAR
FACILITY NUMBER: 197417876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022

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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Per file review and interview with Director, there is no one with current pediatric CPR/First Aid certification present at the facility.
Based on record review, the licensee did not comply with the section cited above in three out of three persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2022
Plan of Correction
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Director will schedule for Director, lead teacher and at least one other staff to complete pediatric CPR/First Aid training and will provide LPA via email with proof of appointment and after completion of training, certificate of completion for referenced persons; no later than 11/11/2022.
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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CLOVER STAR
FACILITY NUMBER: 197417876
VISIT DATE: 10/11/2022
NARRATIVE
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Physical Plant
LPA observed facility sketch that is on file at the El Segundo Child Care Regional Office (ESCCRO). The facility was kept clean, neat and orderly. LPA observed the boys and girls restroom that are utilized by the STAR program. The restrooms are located adjacent to the outdoor central quad area where the children eat snack. Per Health and Safety Code (HSC) 1596.806, this program is exempt from toilet requirements. At the time of inspection, LPA observed both the restrooms to be safe, sanitary and functioning. All poisons and hazardous items are stored in the main STAR classroom. All poisons, dangerous and hazardous materials or items are locked and inaccessible to children in care. All floors are clean and safe. LPA observed the classroom to be clean and free of litter, rubbish and rodents, other vermin, flies, gnats and other insects. Drinking water is readily available both indoors and outdoors.

STAR outdoor play yard is located on the main play yard of the school campus. Per Director, children in the STAR program utilize the central quad area, handball court, kick-ball court and basketball court during outdoor play. Outdoor play area is fenced and free of hazardous and dangerous conditions. Outdoor play equipment is in safe condition and is 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.

FACILITY RECORDS
There is not at least one person present at facility that is trained in CPR and First Aid; this is a potential, health and safety and/or personal rights risk to the children in care. LPA did not observe current Mandated Reporting training on file for the personnel files that were reviewed.

LPA reviewed three (3) staff files of the following personnel records during today's inspection: Staff Qualifications; Proof of immunization of measles (MMR), pertussis (Tdap) and influenza; Current Pediatric CPR and First Aid Certification; TB clearance or risk assessment; LIC 503 (Health Screening Report); LIC 508 (Criminal Record Statement); LIC 9108 (Statement Acknowledging Requirement to Report Child Abuse); Mandated Reporter Training Certificate; LIC 9052 (Employee Rights)

LPA reviewed ten (10) children's files of the following children's records: LIC 613A (Personal Rights); Admission Agreement; LIC 701 (Physician's Report); LIC 995 (Notification of Parents' Rights); LIC 627 (Consent for Emergency Medical Treatment); Immunization Record
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SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 5 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CLOVER STAR
FACILITY NUMBER: 197417876
VISIT DATE: 10/11/2022
NARRATIVE
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LPA observed the following during today's inspection:
  • Facility License
  • Menu
  • PUB 269- Child Passenger Restraint System Poster
  • LIC 610- Emergency Disaster Plan
  • LIC 613A- Personal Rights

LPA provided Director with the following required posting to place on the parent board:
  • PUB 393- Notification of Parents' Rights

LPA reviewed the following documents during today's inspection:
  • Daily Activity Schedule
  • Sign In/Out Sheets


LPA did not observe the following document during the inspection:
  • Verification of Disaster Fire Drills- Per Director, disaster drills have not yet been conducted.

LPA provided Director with the following form for review and completion:
  • LIC 9148 Earthquake Preparedness Checklist


LPA identified the following locations during today's inspection:
  • Medication Storage Area for Children Requiring Permissible Medical Services- LPA observed medication to be properly stored and inaccessible to children in care
  • Functioning Carbon Monoxide Detector, Smoke Alarm(s) and Fire Extinguisher(s)





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SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 4 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CLOVER STAR
FACILITY NUMBER: 197417876
VISIT DATE: 10/11/2022
NARRATIVE
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The following was thoroughly discussed:
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Director was reminded that all adults 18 and over, 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 Child Care Center. 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.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

The facility was not operating in substantial compliance during today’s inspection on 10/11/2022. Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, deficiency cited.

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

Exit interview conducted and report was reviewed with Director, Isaac Olmos.










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SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 8 of 11