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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418383
Report Date: 03/15/2019
Date Signed: 05/05/2019 11:15:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:YESHIVA KETANA OF LOS ANGELES PRESCHOOLFACILITY NUMBER:
197418383
ADMINISTRATOR:FORMAN, ELLENFACILITY TYPE:
850
ADDRESS:12131 BURBANK BLVD.TELEPHONE:
(818) 679-0320
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:60CENSUS: 57DATE:
03/15/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ellen Forman/Director and David Rubenstein/licenseeTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA), Silva Garibyan, met with the director, Ellen Forman, and the licensee, David Rubenstein, upon arrival to the facility. LPA conducted the visit for the purpose of following up on an Unusual Incident report received in the Regional office on 06/08/18 (incident occurred on 06/06/2018).

"The child was in the bathroom and around 11:00 AM the wooden shelf which is located in the bathroom fell. The wooden shelf did not fall on the child, only the items on the shelf which were: coats, bags, and other fluffy items. The child was only scared, but not harmed.

The incident involves a possible lack of supervision and physical plant issues.

LPA interviewed the director and Staff #1/Aide, who witnessed the incident, the licensee, and the director. All three parties stated that the teacher and assistant both were in the classroom and explained that the teacher conducted a circle time, which is located right by the bathroom and the assistant(staff
#1) was standing right by the bathroom doors. They do not know why, but explained the shelf fell off the wall, the child did not endure any injuries from the fallen shelf, some of the items on the shelf made contact with the child. The teacher, who was absent on the day of LPA's visit and was unable to be interviewed. Child #1 was not absent following the incident, however, child #1 is now currently above age and is attending kindergarten.

At this time based on the available information it does not appear this incident was the result of a Title 22 violation.

The content of this report was read and discussed in detail at the time of the visit with the licensee.

An exit interview was conducted; the Notice of Site Visit must be posted for 30 days upon receipt.

SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2019
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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