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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493794
Report Date: 11/13/2019
Date Signed: 11/14/2019 02:56:25 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:VISION PRESCHOOL- SCHOOL AGEFACILITY NUMBER:
197493794
ADMINISTRATOR:KIM, SOOK KIFACILITY TYPE:
840
ADDRESS:20440 LASSEN STREETTELEPHONE:
(818) 895-7643
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:25CENSUS: 0DATE:
11/13/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Sook KimTIME COMPLETED:
04:40 PM
NARRATIVE
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Margarit Sislyan, Licensing Program Analyst (LPA) conducted a case management visit.

During the visit LPA observed that staff #1, Teacher Assistant did not have criminal record clearance,.

Licensee was cited Type A deficiency, according to California Code of Regulations Title 22 See 809D report for deficiencies. A copy of this report must be copied and given to all parents and to the parents of any child enrolling within the next 12 months.

Licensee is to post notice of Site Visit for 30 Days, failure to do so will result in $100 immediate civil penalty.

Exit Interview Conducted


SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit SislyanTELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2019
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 2
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: VISION PRESCHOOL- SCHOOL AGE
FACILITY NUMBER: 197493794
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2019
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department.
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Teachers Assistant Rolze Dominique Unera did not have records of criminal record clearance. This requirement is not met as evidenced by: LPA conducted file review and observed Rolze Dominique Unera is working for the facility without having criminal record clearance.
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Civil Penalty of $1000.00 assessed during the visit.

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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: Margarit SislyanTELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2