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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198005306
Report Date: 01/30/2024
Date Signed: 01/30/2024 01:27:15 PM


Document Has Been Signed on 01/30/2024 01:27 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:HOLY NAME OF MARY SCHOOLFACILITY NUMBER:
198005306
ADMINISTRATOR:ELVIA MONTANEZFACILITY TYPE:
850
ADDRESS:124 S. SAN DIMAS CANYON ROADTELEPHONE:
(909) 542-0449
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:40CENSUS: 32DATE:
01/30/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Elvia MontanezTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jennifer Hua conducted an unannounced annual random inspection. LPA met with Director Elvia Montanez. A COVID-19 risk assessment was conducted prior to entry to the facility. LPA provided a copy of the LIC 125 Entrance Checklist to facilitate the inspection. This is a preschool program. Business hours are from Monday to Friday, 7:45 AM to 3:15 PM.

LPA was guided to a facility tour by Director at 11:17am . All areas identified on the Facility Sketch were inspected. There are 2 classrooms for the preschool program: The following were observed:
  • Classroom 3s - 15 children with 2 staff.
  • Classroom Pre-K - 17 children with 2 staff

The facility was observed to be within the license capacity and limitations. Sign-In and Sign-Out sheets were reviewed.

The following were observed during the tour of the facility:

Furniture and equipment were inspected for age appropriateness and good repair, telephone service, heating, lighting and ventilation were evaluated. All floors were observed to be clean and safe. All materials accessible to children were observed to be toxic free. Per Director, there were no firearms stored on the premises and no pools or bodies of water. Children have their own cubby to store their belongings. Mats are stacked. Blankets/sheets are sent home to be wash every Friday. Per Director, the isolation area is in the director's office area. Age appropriate sinks and toilets were inspected for availability and good repair in all restrooms. General sanitation was observed. Availability of indoor drinking water was observed in the classroom. First Aid supplies were on top cabinet in every classroom.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOLY NAME OF MARY SCHOOL
FACILITY NUMBER: 198005306
VISIT DATE: 01/30/2024
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Disinfectants, cleaning solutions, and other items that are dangerous to children were inaccessible. Carbon monoxide and smoke detectors were observed in the classrooms. All kitchen areas/food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin.
All storage containers for solid waste, including moveable bins have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids. Facility provide snacks for children. Lunch is catered and brought in daily or kids can bring their own lunch. Parent sign up for the lunch program. Menu was observed to be posted for the month. Drills conducted on 10/3/2023 & 10/19/2023.

Outdoor playground equipment is in a safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. The outdoor surface is cushioned with built in rubber that absorbs a fall. There is adequate shade in the play yard. LPA observed drinking fountain. LPA advised that no children shall be left without the supervision of a teacher at any time.

All individuals present have obtained a criminal record clearance or criminal record exemption. There is at least one person trained in CPR and Pediatric First Aid present during this inspection. The review of Staff records was documented on the LIC 859. Staff present have proof of the AB 1207 Mandated Reporter Training, Staff present have proof against TB, measles, pertussis, and influenza.



This facility provides Incidental Medical Services - IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children's, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOLY NAME OF MARY SCHOOL
FACILITY NUMBER: 198005306
VISIT DATE: 01/30/2024
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/tion-process.

Deficiencies cited on attached 809D.

A notice of site visit was given and must remain posted for 30 days or a civil penalty of $100 will be assessed.

Exit interview conducted and report was reviewed with Director. Copy provided.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 01/30/2024 01:27 PM - It Cannot Be Edited

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: HOLY NAME OF MARY SCHOOL
FACILITY NUMBER: 198005306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in water lead test has not been done as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Per director will correct and submit all required documents - LIC 9275, LIC 9276, lab test result, facility sketch, pictures, to LPA by POC due date.
Type B
Section Cited
WD
101700(b)
Written Directives for Lead Testing
(b) All licensed Child Care Centers operating in buildings constructed before January 1, 2010, shall test their water for lead pursuant to these written directives.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in water lead test has not been done as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Per director will correct and submit all required documents - LIC 9275, LIC 9276, lab test result, facility sketch, pictures, to LPA by POC due date.
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4