198001552-5-13-2022-33-CC-FVAZ-CEDVKH-20220513163022

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198001552
Report Date: 05/13/2022
Date Signed: 05/13/2022 04:30:38 PM

Document Has Been Signed on 05/13/2022 04:30 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: 93	DATE:	05/13/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:37 PM
MET WITH:	Executive Director, Judy Krause		TIME COMPLETED:	04:45 PM

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On 05/13/22 Licensing Program Analyst (LPA) Fabiola Vasquez conducted an unannounced case management inspection due to an incident that occurred on 05/03 22. LPA met with Associate Director (AD), Victor Soto, who guided LPA on a tour of the facility.

There were 93 children and 20 staff present upon arrival.

Executive Director, Judy Krause (ED) arrived at approximately 11:20 AM who continued with the inspection.

LPA Vasquez conducted interviews with C1, S1, S2 and a visual tour of the area where the incident occurred.
The incident that occurred on 05/03/22 was reported to the Department on 05/04/22 vie email. The facility reported the Unusual Incident to the Department within the required 24 hours of occurrence.

C#1 while playing in the Peppers Yard, was running through the sand box to retrieve a shovel. He slipped in the sand landing with his mouth hitting the shelf that holds the creates of sand toys. He cut his lip open and lost a tooth which we assumed he swallowed. The incident resulted in the child having to go to the dentist.

Based on LPA's observation, and interviews conducted with C1, S1, and S2. A statement was made by C1 I forgot to stop, other collaborating statement made by C1, S1, S2 that there were no toys on the sandbox for C1 to slipped on. Per C1 he fell on his own. Child was provided first aid and returned the next day to school. There is no follow up is necessary regarding the incident.

There were no deficiencies cited on this date.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days. Exit interview was conducted with Judy Krause, Executive Director, including, but not limited to Provider Rights, Appeal Procedures

Claudia Guangorena
Fabiola Vasquez
	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

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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