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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494574
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:50:24 PM


Document Has Been Signed on 03/30/2022 03:50 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:DEVONSHIRE PRESCHOOLFACILITY NUMBER:
197494574
ADMINISTRATOR:MERADITH GRABLEFACILITY TYPE:
850
ADDRESS:21203 DEVONSHIRE STREETTELEPHONE:
8187002821
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:60CENSUS: 57DATE:
03/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Amalia Gutierrez, Director Assistant and Licensee Marian Ranasinhe TIME COMPLETED:
03:55 PM
NARRATIVE
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On 03/30/2022, Licensing Program Analyst (LPA) Denise Miranda conducted a Case Management for the purpose of the health and safety of the child care center.

The following were observed:

LPA reviewed 07 Staff files and observed that all files were not in compliance.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D)

An exit interview was conducted and a copy of this report, appeal rights and Notice of Site Visit was provided to Marian Renasinhe, Licensee.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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


Document Has Been Signed on 03/30/2022 03:50 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: DEVONSHIRE PRESCHOOL
FACILITY NUMBER: 197494574

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2022
Section Cited

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101216(l) Personnel Requirements (l) All personnel shall be informed of their rights pursuant to Sections 1596.881 and 1596.882 of the Health and Safety Code.
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Based on records review. LPA reviewed 07 files they are incompleted. Which poses a potential Health or Safety, or personal rights risk to persons in care.
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LPA provided a copy of LIC311aa (Records to be Maintain at the Faciltiy - Child Care Centes).

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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: Claudia EscobedoTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2