198001552-11-20-2023-33-CC-NTCG-CXS2HK-20231120162451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198001552
Report Date: 11/20/2023
Date Signed: 11/20/2023 04:24:56 PM

Document Has Been Signed on 11/20/2023 04:24 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
L.A. DAY CARE-EAST, 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: 61	DATE:	11/20/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Victor Soto - Director		TIME COMPLETED:	04:38 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Nolan Tcheng and Suzana Safaryan conducted an unannounced Case Management inspection for the purpose of following up on an incident report submitted to the department on 11/03/2023. Upon arrival at 2:15pm, LPAs met with Director Victor Soto, to whom the purpose of the inspection was explained. Tour was provided. There were children present during the time of inspection. Census was taken. There were 61 children with 16 staff members.

On 11/01/2023, a child was running with a friend on the play yard. Child went to hide behind a storage shed and tripped, bumping the back of their head on the gate. The injury resulted in the child getting staples. Interviews were conducted with four staff members during today's inspection. Per staff interviews, all staff present during the incident did not observe the injury taking place but observed the child crying following the incident taking place. This incident is a violation of supervision at the facility.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 Chapter 1 Section 101229(a)(1), is being cited on the attached deficiencies page.

Upon receipt of this report, the Licensee shall post the Notice of Site visit and any licensing report documenting a type “A” deficiency. The report and the Notice of Site visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee. REPORT CONTINUES PAGE 1 of 2

Claudia Guangorena
Nolan Tcheng
	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC OAKS CHILDREN'S SCHOOL	FACILITY NUMBER: 198001552
	VISIT DATE: 11/20/2023

NARRATIVE

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A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director Victor Soto, at 3:50pm. Copy of Report provided.

END OF REPORT PAGE 2 of 2

SUPERVISOR'S NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/20/2023 04:24 PM - It Cannot Be Edited

Created By: Nolan Tcheng On 11/20/2023 at 03:33 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC OAKS CHILDREN'S SCHOOL	FACILITY NUMBER: 198001552
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/21/2023 Section Cited	1 2 3 4 5 6 7	Responsibility For Providing Care and Supervision (1) No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interview and record review, Licensee did not ensure that visual supervision was provided at all times, resulting in a child sustaining a head injury requiring medical treatment. This posed an immediate risk to the health, safety, and personal rights of children in care.	8 9 10 11 12 13 14	watched by all staff and summary of video with siganture will be submitted to LPA by POC date.
	1 2 3 4 5 6 7
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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 Guangorena

LICENSING EVALUATOR NAME:

Nolan Tcheng

LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

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