198004790-5-2-2019-54-CC-AJLO-BBSRM4-20190502130808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198004790
Report Date: 05/02/2019
Date Signed: 05/02/2019 01:08:19 PM

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	ST. JOHN OF GOD PRE-K		FACILITY NUMBER:	198004790
ADMINISTRATOR:	TRACIE GUTIERREZ		FACILITY TYPE:	850
ADDRESS:	13817 PIONEER BLVD.		TELEPHONE:	(562) 863-5721
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	20	CENSUS: 5	DATE:	05/02/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Tracie Gutierrez, Director		TIME COMPLETED:	01:20 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	An unannounced Annual Random Inspection was conducted on this day by Licensing Program Analysts (LPAs) A. Lucero and D. Gibbs. Facility is currently licensed for a capacity of 20 preschool children. Licensing staff met with Director Tracie Gutierrez who guided LPAs on an indoor and outdoor tour of the facility. The program currently operates Monday through Friday from 8:00am to 3:00pm. Upon LPAs arrival to the facility, Staff #1 stated that Director Tracie Gutierrez was teaching in the Transitional Kindergarten classroom. Director stated that she wishes to update the facility file to reflect that the preschool wishes to change the age group to ages 2 through 4 years of age. LPA provided Director with the LIC 200A to fill out and submit to the department. At the initial start of the site visit, there is a total census of five preschool children with one teacher present. Furniture and equipment was inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Storage for children's belongings was observed. Mat/cot was inspected. Availability of drinking water was reviewed. Age appropriate sinks and toilets were inspected for availability, good repair, water temperature, toilet paper, area safety and sanitation. Toys observed to be clean. A first aid kit is kept in the classroom. Carbon monoxide detectors and smoke detectors are present in the facility and are in operational condition. Fire extinguishers have been serviced in 08/2018. Hazardous items including poisonous cleaning compounds were stored inaccessible to children. Snack/lunch menus were reviewed. Food and snacks were reviewed for availability, quantity and appropriateness to children in care. Food preparation areas were toured for safety, cleanliness and proper equipment. Facility provides a morning snack to children in care. Lunch is provided by parents. Facility does not provide an afternoon snack to children in care. Full-day programs shall offer a midmorning and a midafternoon snack.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019

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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JOHN OF GOD PRE-K	FACILITY NUMBER: 198004790
	VISIT DATE: 05/02/2019

NARRATIVE

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The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and Carbon Monoxide detectors should be checked and batteries replaced as needed. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your location.

Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed. Role and responsibilities of being a Mandated Reporter were reviewed. The Director was advised how to access forms and Regulations online at www.ccld.ca.gov. Director was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care. The Director was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care.

LPA advised Director that all adults 18 years of age and older providing Care & Supervision and/or have continuous presence in the facility shall adhere to a criminal background clearance with the Department of Justice, FBI and Child Abuse Index Check. LPA informed Director to log onto web site www.ccld.ca.gov to obtain forms and LIVE SCAN application.

Records for all children and staff must be maintained for three (3) years after separation from the facility. The Director was also advised of the requirement to report Unusual Incidents and/or injuries to the parent/guardian and to CCL within the time frame specified by the regulation. Director advised that indoor and outdoor supervision required at all times. If outdoor area not adequately fenced, provider must be with children at all times when outdoors.

See deficiencies page for deficiencies cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1

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.

Exit interview, copy of report was given. Appeal rights were issued and discussed.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019

LIC809 (FAS) - (06/04)

Page: 3 of 4

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JOHN OF GOD PRE-K	FACILITY NUMBER: 198004790
	VISIT DATE: 05/02/2019

NARRATIVE

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Outdoor equipment was inspected for safety, cushioning material, good repair and appropriateness. Required shade, drinking water and fencing were inspected. LPA Lucero advised Director that the children need to be within the direct care and supervision, including visual supervision of the teacher(s) at all times. The children have access to drinking fountains during outside play. Play area was inspected for hazards and inaccessibility to bodies of water; no bodies of water or hazards observed.

Teacher-child ratios were observed and staff names recorded. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate. Sign-in and out sheets and procedures were reviewed. Personal Rights of children were observed by LPA.

Staff and Children’s Records were reviewed. LPA determined that child #1 had an incorrect LIC 701 form. Criminal Record Clearances were reviewed for adults. LPA determined that Principal Elizabeth Mendez is fingerprinted with the Archdiocese; however, is not fingerprinted with the Department. This is an immediate risk to children in care. A civil penalty of $100 was assessed on this day. CPR card expires in 04/2020 for Director Tracie Gutierrez. Inspection of required forms made.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The following was discussed with the Director:

Rooms that are off-limits need to be made inaccessible during operating hours. Smoking is prohibited. The Director was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. LPA also provided a complete packet of the Provider Information Network (PIN) 10-02-CCP dated February 20, 2019 regarding Safe Sleep Awareness Campaign during today’s inspection.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019

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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JOHN OF GOD PRE-K	FACILITY NUMBER: 198004790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/02/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/03/2019 Section Cited CCR 101170(e)(2)	1 2 3 4 5 6 7	Criminal Record Clearance Request a transfer of a criminal record clearance as specified in Section 101170(f) The requirement is not met as evidenced by: During review, LPA determined that Principal Elizabeth Mendez is fingerpritned, however, not through the Department. This is a potential risk.	1 2 3 4 5 6 7	Director stated that she will have Principal fingerprinted. Director will email LPA a copy of receipt of fingerprints conducted by POC date of 5/3/19.
Type B 05/16/2019 Section Cited CCR 101227(5)(a)	1 2 3 4 5 6 7	Food Services Full-day programs shall offer a midmorning and a midafternoon snack. The requirement is not met as evidenced by: During review of faciltiy, LPA determined that the facility does not provide an afternoon snack. This is a potential risk to children.	1 2 3 4 5 6 7	Director stated that facility will provide an afternoon snack to children. Director will submit a Menu to LPA of the afternoon snack that will be provided by POC date of 5/16/19.
Type B 05/30/2019 Section Cited CCR 101621	1 2 3 4 5 6 7	Child's Records The requirement is not met as evidenced by: During records review, LPA determined that child #1 has a LIC 701 from another preschool. This is a potential risk to children in care.	1 2 3 4 5 6 7	Director stated that she will supply parent with the LIC 701 form and have parent submit completed form. Director will email LPA a copy of the LIC 701 form by POC date of 5/30/19.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019

LIC809 (FAS) - (06/04)

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