198001552-10-20-2021-33-CC-FVAZ-C7YQNN-20211020121925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198001552
Report Date: 10/20/2021
Date Signed: 10/20/2021 12:19:30 PM

Document Has Been Signed on 10/20/2021 12:19 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	PACIFIC OAKS CHILDREN'S SCHOOL		FACILITY NUMBER:	198001552
ADMINISTRATOR:	ROBERT BOYMAN		FACILITY TYPE:	850
ADDRESS:	714 W. CALIFORNIA BLVD.		TELEPHONE:	(626) 529-8011
CITY:	PASADENA	STATE: CA	ZIP CODE:	91105
CAPACITY: 140	TOTAL ENROLLED CHILDREN: 140	CENSUS: 94	DATE:	10/20/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Judy Krause		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fabiola Vasquez conducted a case management inspection due to an incident that occurred on 09/30/21. LPA met Director, Judy Krause, who guided LPA on a tour of the facility at approximately 09:30 AM. During this inspection LPA observed 15 children with 03 staff in the Tierra group class, 05 children with 01 staff in the Explorer class , 12 children with 02 staff in the El Arroyo Class, 15 children with 03 staff in the Peppers Class, 05 children with 01 staff in the Sunflower Class, 06 children with 02 staff in the Lo Loma class, 08 children with 02 staff in the half day Lo Loma Class, 14 children with 02 staff in the Boat Yard Class, 14 children with 02 staff in the bamboo class. The incident that occurred on 09/30/21 was reported to the Department on 10/01/21. The facility reported the incident in a timely manner. LPA conducted an interview with Director, S1. Obtained copies of the sign in sheet, current children's roster, and ouch report. 9/30/21 Child was climbing the wooden steps to go onto the play structure, lost footing and fell forward bumping the right side of the forehead, above the eyebrow The injury required medical attention child was taken to Urgent Care requiring stitches. 10/20/21 LPA visually observed the space where the incident occurred. LPA observed the play structure and the wooden steps to climb onto the structure. LPA observed the step the child attempted to climb which is the first step off the ground. The steps were observed to be in good condition and are secured on the ground. The area around the play structure and the steps were the incident occurred has foam chips all around the that can absorb a child's fall. PAGE 1 OF 2

Claudia Guangorena
Fabiola Vasquez
	DATE: 10/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC OAKS CHILDREN'S SCHOOL	FACILITY NUMBER: 198001552
	VISIT DATE: 10/20/2021

NARRATIVE

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Based on all information obtained on this date, no follow-up is necessary regarding the incident. The incident appears to be an unusual accident. It appears to be nothing the facility staff could have done to prevent the incident from occurring the supervision was appropriate and Per director , S1 and LPAs observation the teacher was standing 3 feet from the child.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.
Exit interview was conducted with Director Judy Krause, Appeal rights explained & provided.

There were no deficiencies cited during today’s inspection

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SUPERVISOR'S NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

LIC809 (FAS) - (06/04)

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