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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417919
Report Date: 05/10/2022
Date Signed: 05/10/2022 05:23:23 PM


Document Has Been Signed on 05/10/2022 05:23 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:WEST HOLLYWOOD STARFACILITY NUMBER:
197417919
ADMINISTRATOR:ANGELO GONZALESFACILITY TYPE:
840
ADDRESS:970 N. HAMMONDTELEPHONE:
3106788486
CITY:WEST HOLLYWOODSTATE: CAZIP CODE:
90069
CAPACITY:90CENSUS: 31DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Adam Nickerson, Director TIME COMPLETED:
05:30 PM
NARRATIVE
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On 5/10/2022 1:50pm, Licensing Program Analyst (LPA) Miranda conducted an unannounced Required 1- Year Inspection to the facility. At 2:08 PM, LPA met with Director Adam Nickerson. According to the center director, the facility operates: Monday, Wednesday, Thursday and Friday from 2:30pm – 6:00pm and Tuesday 1:30pm to 6:00pm. At 2:08pm LPA was guided on a tour of the facility inside and outside. The facility currently Facility is located on the campus of West Hollywood Elementary School, child care is provided in the classroom#1, # and #4, auditorium and play yard which are located towards the back of the school campus.
LPA Miranda observed 31 school age children under supervision of 2 staff and Director . LPA observed all children are under supervision, including visual supervision, of a teacher at all times.
Furniture and equipment are in good condition, free of sharp, loose or pointed parts. All materials and surfaces accessible to children are toxic free. All toilets and handwashing facilities are in safe and sanitary operating condition. All floors in the facility are clean and safe. School provide all snack and keep in storage at the cafeteria area. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors.
Playground equipment is in safe condition, free of sharp, loose or pointed parts. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible. No poisons were observed during the inspection.

The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition allowed or stored on the premises.
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: WEST HOLLYWOOD STAR
FACILITY NUMBER: 197417919
VISIT DATE: 05/10/2022
NARRATIVE
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The facility is free of flies, insects and rodents. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. The child care center was observed to be clean, safe, sanitary and in good repair.
LPA verified staff have received a criminal record clearance or exemption. LPA advised upon notification from the Department, the licensee will comply and act immediately to terminate the employment of, remove from the facility or bar from entering the facility for any person it is deemed necessary while the Department considers granting or denying an exemption.

Capacity and limitations as specified on the license are being maintained. No proof of a staff with trained in CPR and Pediatric First Aid present when children are at the facility or at offsite activities during this inspection. The name of the child care center director or fully-qualified teacher(s) designated to act in the director’s absence has been reported to the Department. LPA observed sign in/out sheet and verified the person who signs the child in/out of the facility is using their full legal signature and recording the time of day.

Facility maintains a ratio of one teacher supervising no more than 14 children in care. The facility is equipped to isolate and care for any child who becomes ill during the day. LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment. LPA was unable to reviewed staff files, director was unable to provide copy of complete with health screening, immunization records for influenza, pertussis and measles and current documentation of completed mandated reporter training was expired for two staff. Menus are posted at least one week in advance where an authorized representative can view them. Incidental Medical Services (IMS) are not currently being provided. Director is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800)514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
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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: WEST HOLLYWOOD STAR
FACILITY NUMBER: 197417919
VISIT DATE: 05/10/2022
NARRATIVE
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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, 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 or after school program. 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.

LPA and Director discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, , Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, deficiencies are cited.

Director was provided a copy of their appeal rights and a notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Adam Nickerson, Director.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/10/2022 05:23 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: WEST HOLLYWOOD STAR
FACILITY NUMBER: 197417919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Director did not comply with the section cited above in Disater drill. Director was unable to produce copy of the Disaster log which posesposed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Per Director copy of fire drill will be submit via email to LPA Miranda
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 observation, interview, record review, the Director did not comply with the section cited above in Immunization record. Director was unable to provide copy of immunization record to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Per Director a copy of staff#1, Staff#2 and Director immunization will be submit via email to LPA Miranda.

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: Denise MirandaTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2022 05:23 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: WEST HOLLYWOOD STAR
FACILITY NUMBER: 197417919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation, interview, record review, the Director did not comply with the section cited above in Mandated report training were observed that staff#1 and Director had expired mandated report on 1/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Per Director copy of completion of mandated reporter training will be submit via email to LPA Miranda.
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 observation, interview, and record review, the Director did not comply with the section cited above in training in pediatric cardiopulmonnary resuscitation and pediatric aid. Director was unable to produce a proof of CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Per Director copy of current CPR card will be submit via email to LPA Miranda

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: Denise MirandaTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 05/10/2022 05:23 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: WEST HOLLYWOOD STAR
FACILITY NUMBER: 197417919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216.1(b)(2)
Teacher Qualifications and Duties
(2) A teacher shall meet the requirements of Health and Safety Code Section 1597.055.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Director did not comply with the section cited above in safety code section 1597.055, no files and/or any document was available for review during this inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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LPA provided copy of LIC311A and Director agreed to submit staff documents no later than 5/20/2022
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Director did not comply with the section cited above that personnel records are not maintained for each employee and be available for inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Director agreed to create files and maintain accessible on facility.

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: Denise MirandaTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 05/10/2022 05:23 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: WEST HOLLYWOOD STAR
FACILITY NUMBER: 197417919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)(6)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (6) Documentation of the educational background, training and/or experience specified in this chapter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Director did not comply with the section cited above in personnel records. Director was unable to produce proof of staff education during this inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Director agreed to provide copy via email no later than 5/20/2022
Type B
Section Cited
CCR
101217(d)
Personnel Records
(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review,, the licensee did not comply with the section cited above in do not have files available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Director agreed to provided a declaration (LIC855), that he understand, files shall be availalbe for review during inspections Director will be provide via email to LPA

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: Denise MirandaTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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