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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001552
Report Date: 11/09/2021
Date Signed: 11/09/2021 11:11:28 AM

Document Has Been Signed on 11/09/2021 11:11 AM - 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 SCHOOLFACILITY NUMBER:
198001552
ADMINISTRATOR:ROBERT BOYMANFACILITY TYPE:
850
ADDRESS:714 W. CALIFORNIA BLVD.TELEPHONE:
(626) 529-8011
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: 140TOTAL ENROLLED CHILDREN: 140CENSUS: 91DATE:
11/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Judy KrauseTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Fabiola Vasquez conducted a case management inspection due to an incident that occurred on 10/26/21. LPA met Director, Judy Krause, who guided LPA on a tour of the facility at approximately 09:00 AM. During this inspection LPA observed.

12 children with 03 staff in the Tierra group class, 05 children with 01 staff in the Explorer class, 12 children with 03 staff in the El Arroyo Class, 14 children with 02 staff in the Peppers Class, 06 children with 01 staff in the Sunflower Class, 11 children with 02 staff in the Lo Loma class, 09 children with 02 staff in the half day Lo Loma Class,
10 children with 03 staff in the Boat Yard Class, 12 children with 03 staff in the bamboo class.

The incident that occurred on 10/26/21 was reported to the Department on 10/27/21. The facility reported the incident in a timely manner.

LPA conducted an interview with Director, S1 and S2. Obtained copies of the sign in sheet, current children's roster, and an ouch report. Per director she will submit doctor’s note to LPA.

On 10/26/21at approximately 10:00 AM, child was brought inside for a diaper change, child began to twirl around in the carpet area child fell and began to cry. S1 asked where does it hurt? It took a minute for S1 to figure out it was the right leg. There were no bumps, bruising or swelling. S1 applied ice, changed the diaper and brought the child outside. Child cried for a bit and continued to play in the yard. During pickup at 12:30 PM the mother was informed of the incident and given an ouch report. Mother took child to urgent care on 10/27/21 it was discovered fractured his right tibula. Child was applied a soft cast and an appointment was made to the Otho.

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Claudia Guangorena
Fabiola Vasquez
DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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: 11/09/2021
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11/09/21 LPA visually observed the carpet space where the incident occurred. Statements were made by S1 and S2 that the carpet was empty there was no other children, toys or furniture around. A statement made by S1; child tripped over his own leg. LPA observed the area to be free from objects that could have caused fall. It appears to be nothing the facility staff could have done to prevent the incident from occurring.

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.

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: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
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