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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419005
Report Date: 06/07/2019
Date Signed: 06/17/2019 07:11:38 AM

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:CII/SOUTH VERMONT HEAD STARTFACILITY NUMBER:
197419005
ADMINISTRATOR:TELMA CEAFACILITY TYPE:
850
ADDRESS:9022 S. VERMONTTELEPHONE:
(213) 385-5100
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY:55CENSUS: 16DATE:
06/07/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Telma Cea/site supervisorTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Silva Garibyan arrived at the above facility to conduct a Case Management Incident inspection. The self - reported incident occurred at CII South Vermont Site on 05/08/19. The El Segundo Regional Office received the incident report on 05/09/19. Upon arrival, LPA observed proper care and supervision. All center staff that was present during today’s inspection had fingerprint cleared and associated to the designated license number.

" Date: 5/8/19, Time: 1:50 pm, Location: 1pm/Bathroom
Staff #1 took approximately 6 to 8 children to the restroom, when Staff #1 walked back to classroom area, Staff#1 heard a child cry and walked back to the restroom, Child #1 was left in the bathroom by herself/himself for less than a minute."

The incident involves a possible lack of supervision issues.

Based on the information obtained from the interviews conducted Child #1 was left inside the restroom while the remaining children left the restroom. The restroom is inside the classroom. California Code of Regulations, Title 22, Division 12, Chapter 1, Article 06, Section 101229 (a)(1) is being cited on the attached LIC 809D page. Appeal rights were discussed and printed. Copy of this report was provided, Notice of Site visit issued.
Exit interview was conducted.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
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: CII/SOUTH VERMONT HEAD START
FACILITY NUMBER: 197419005
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2019
Section Cited
CCR
101229(a)(1)
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Responsibility for Providing Care and Supervision
No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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One of the classroom staff was immediately removed and replaced.
Licensee will submit a written plan of correction by 06/21/19, indicating the course of action taken and/or training provided to ensure this type of incident does not reoccur.
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This requirement is not met as evidenced by: Child #1 was left in the restroom inside the classroom while the remaining children left the restroom
This is a type B dificiency as poses a potential risk to the health and safety of 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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
LIC809 (FAS) - (06/04)
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