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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417971
Report Date: 06/13/2019
Date Signed: 06/13/2019 03:12:52 PM

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:ENCOREFACILITY NUMBER:
197417971
ADMINISTRATOR:KIM, MI OK (IRENE)FACILITY TYPE:
850
ADDRESS:989 S. ST. ANDREWS PLACETELEPHONE:
(213) 249-8658
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:40; 40CENSUS: 28DATE:
06/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Diane Han, Assistant DirectorTIME COMPLETED:
03:15 PM
NARRATIVE
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On 06/13/2019 at 12:55 pm, Licensing Program Analyst (LPA) Sabrina Martinez conducted an unannounced visit at the facility for the purpose of following up on the unusual incident that occurred at the facility on 05/30/2019. The El Segundo Regional Child Care Office received the report via phone call on 05/31/2019.

According to the report, on 05/31/2019 around 11:30 am, during lunch time, child #1 saw staff #1's purse with M&M's inside. Staff #1 gave the child peanut M&M's. RP states that the facility is peanut free and does not allow outside food and that staff #1 is aware of the child's peanut allergy. RP states that the child asked for water and threw up. RP states that the child's parents were immediately called to the facility and the child was immediately picked up.

LPA met with Diane Han, Assistant Director, and discussed the purpose of the visit. During this inspection, LPA conducted interviews with facility staff and the child’s parent.

Based on the information gathered throughout the course of the investigation, it was revealed that staff #1 served child food that he was allergic to. Furthermore, facility was made aware of the child's peanut allergy however failed to update the child's record to ensure the accuracy of the child's record. Type A and B citations will be issued today, 06/13/2019. See LIC 809-D for deficiencies cited.

Upon receipt of the Type A Violation(s), licensee shall post the report for 30 days in addition to the Notice of Site Visit, provide copies of the licensing report to parents/guardians of children in care at the facility and obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file by the close of business the following day or the next day child returns to the facility.

A copy of this report, notice of site visit and appeal rights were provided and an exit interview was conducted with Diane Han, Assistant Director.

SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
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: ENCORE
FACILITY NUMBER: 197417971
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2019
Section Cited
CCR
101221(f)
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Child's Records. The information specified in (b)(1) through (b)(12) above shall be updated as necessary to ensure the accuracy of the child's record. This requirement is not met as evidenced by: On 06/13/19, a review of child#1's records were conducted and LPA did not observe the records to be updated.
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Facility will update records of children who are currently enrolled to ensure all required documents are included and updated no later than 07/13/2019.
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This is a potential health and safety risk to children in care.
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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: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: ENCORE
FACILITY NUMBER: 197417971
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2019
Section Cited
CCR
101223(a)(2)
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Personal Rights. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by: Based on evidences gathered, it was revealed that on 05/30/19, staff #1 served
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The facility will conduct staff meeting discussing the school's allergy policy.

A copy of the meeting agenda as well as the staff sign in sheet will be scanned and emailed to the Department no later than close of business day on 06/14/2019.
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child food that he was allergic to. This is an immediate health and safety risk to children in care.
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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: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
LIC809 (FAS) - (06/04)
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