198006185-1-17-2023-33-CC-AEIN-CN6RHT-20230117120253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198006185
Report Date: 01/17/2023
Date Signed: 01/17/2023 12:03:04 PM

Document Has Been Signed on 01/17/2023 12:03 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:	COLUMBUS STATE PRESCHOOL		FACILITY NUMBER:	198006185
ADMINISTRATOR:	ANA MENA		FACILITY TYPE:	850
ADDRESS:	425 W. MILFORD STREET		TELEPHONE:	(818) 241-3111
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91203
CAPACITY: 26	TOTAL ENROLLED CHILDREN: 36	CENSUS: 16	DATE:	01/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Perla Leyvas, Program Supervisor		TIME COMPLETED:	12:20 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	Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced Required- 1 year inspection on 01/17/2023 at 8:50 AM. LPA went to the school office and was guided to the preschool classroom. Upon LPA's arrival to the preschool classroom, there were 16 preschoolers with 4 staff. At 9:10 AM, Perla Leyvas, Program Supervisor arrived to the facility and guided LPA on a tour of the facility. LPA provided Perla Leyvas with a copy of the Entrance Checklist for Child Care Centers form (LIC 125). This is a preschool program which consists of 1 classroom; RM 1105 . This facility is located on Columbus Elementary School property. This facility is one of Glendale Unified School District sites. This is a A COVID 19 risk assessment was conducted prior to entering the facility. All areas identified on the Facility Sketch were inspected. Upon arrival, the following staff were present during this inspection; Preschool Room 1105: Four staff with 16 preschoolers in the classroom. The facility was observed to be within the license capacity and limitations. Staff names were recorded. All children were observed to be under visual supervision of a teacher at all times. Parents enter through classroom door entrance adjacent to classroom and leads to the Milford Street. The program operates AM and PM. AM program operates Monday- Friday 8:30 AM to 11:30 AM, and The PM program operates Monday - Friday 12:30 PM to 3:30 PM. The following was observed during the tour of the facility: PHYSICAL PLANT LPA observed the facility to be clean, safe, sanitary and in good repair. Per program supervisor, cleaning crew clean the preschool classroom daily after school hours. Furniture and equipment was inspected for age appropriateness and good repair, free of sharp, loose, or pointed parts. All indoor classrooms were inspected to ensure that the floors have a surface that is safe and clean. All materials accessible to children were observed to be toxic-free. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubby to store their belongings inside the classroom. Per Program Supervisor, Perla Leyvas REPORT CONTINUES ON NEXT PAGE 1 OF 4

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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 6

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: COLUMBUS STATE PRESCHOOL	FACILITY NUMBER: 198006185
	VISIT DATE: 01/17/2023

NARRATIVE

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children do not take nap in this program. Age appropriate sinks and toilets were inspected for availability and good repair in all restrooms. Two restrooms are located inside the classroom. General sanitation was observed. Availability of indoor drinking water was observed in the classroom. Per Perla Leyvas, Program Supervisor children use their water bottles for drinking water indoor.

Disinfectants, cleaning solutions, medication, and other items that are dangerous to children, were inaccessible to children. Perla Leyavas, Program Supervisor states at 10:00 AM, there are no poisons stored at the facility. Per Perla Leyvas, Program Supervisor, there is not a working carbon monoxide detector in the preschool classroom during this inspection. Trash cans used to discard food have tight fitting lids or solid waste bags shall be discarded immediately after each meal.

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. All areas around or under high climbing equipment, slides, and similar equipment are cushioned with sand and grass cushioning material that absorbs a fall; climbing apparatuses are single level only. There is adequate shade in the play yard. Program utilizes TK and Kindergarten play yard for outdoor activity. Waiver on file. Availability of outdoor drinking water was observed. Per Perla Leyvas, Program Supervisor teachers take water pitcher and disposable cups outside for drinking water. LPA advised that no children shall be left without the supervision of a teacher at any time.

Per Perla Leyvas at 10:30 AM, there are no bodies of water on the premises and LPA did not observe any bodies of water during this inspection. Program Supervisor states there are no weapons or firearms on the premises.

FACILITY RECORDS

Program Supervisor, Perla Leyvas was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

REPORT CONTINUES ON NEXT PAGE 2 OF 4

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: COLUMBUS STATE PRESCHOOL	FACILITY NUMBER: 198006185
	VISIT DATE: 01/17/2023

NARRATIVE

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Children’s Records were reviewed for completeness; Inspection of required forms was made and documented on the LIC 857.

There is at least one person trained in CPR and Pediatric First Aid present during this inspection. LPA also reviewed staff records. The review of Staff records was documented on the LIC 859. Staff present had proof of the AB 1207 Mandated Reporter Training certificate on file. LPA reviewed five staff files and 2 out of 5 reviewed staff files did not have proof measles and pertussis on file. All five staff reviewed files had proof against TB on files. All staff have been given on the-job training sanitation principles, housekeeping, including universal health precautions.

Children's roster was reviewed and is current. Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. LPA observed sign in/out sheet was placed inside by the entrance door. During this inspection 16 children were present, and all 16 children were singed in. Disaster drill log was available, last drill was conducted on 12/09/2022.

Menus are posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request. Snacks were reviewed for availability, quantity and appropriateness to children in care. Per Perla Leyvas, Program Supervisor at 10:45 AM meals are prepared by Glendale Unified School District. The facility provides lunch to AM and PM program. Children are served lunch in the classroom.

First Aid supplies were observed in the classroom in storage area in a cabinet. According to Perla Leyvas, Program Supervisor at 10:50 AM, medication is only administered to a child when accompanied with a doctor's note and is stored in the child’s classroom. The facility was observed to be equipped with an isolation area for any child who becomes ill and it is located in the school Nurse office. The ill child will use the Nurse office restroom during isolation which is disinfected immediately after use per Site Supervisor.

REPORT CONTINUES ON NEXT PAGE 3 OF 4

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

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: COLUMBUS STATE PRESCHOOL	FACILITY NUMBER: 198006185
	VISIT DATE: 01/17/2023

NARRATIVE

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Medication: This facility provides Incidental Medical Services – IMS. Per Perla Leyvas, Program Supervisor currently enrolled children do not need IMS. 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. Plan of Operation for Incidental Medical Services on file.

At 11:00 AM LPA reviewed new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, which requires the testing of water for lead in Child Care Centers (CCCs) with facility director during the inspection. Per AB 2370, all CCCs that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.
Per Perla Leyvas, Program Supervisor at 10:50 AM, children do not use facility faucet water for drinking. Per Program Supervisor, facility provides water bottles for drinking. LPA observed a pack of 40 water bottles in the storage area. LPA informed Perla Leyvas, Program Supervisor they are required to request a waiver from Water Lead Testing at this time if they do not use faucet water for drinking. During this inspection water fountain in the preschool classroom was accessible and working. (Pictures were taken).

LPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.
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/process.

The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D for deficiencies that are being cited and need to be cleared to protect the children’s health & safety.
A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the Program Supervisor, Perla Leyvas at 12:20 PM.

END OF REPORT PAGE 4 OF 4

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 01/17/2023 12:03 PM - It Cannot Be Edited

Created By: Anomeh Eivazian On 01/17/2023 at 11:14 AM

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: COLUMBUS STATE PRESCHOOL	FACILITY NUMBER: 198006185
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.954

Licensure Requirements

Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on tour of the facility, the licensee did not comply with the section cited above and there is not a working Carbon Monoxide Detector available in the preschool classroom during this inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2023
	Plan of Correction
1 2 3 4	Per Program Supervisor, Perla Leyvas school district were in impression that if there is no gas connection in the classroom they are exempt from this requirement. LPA provided a copy of H&S Code 1596.954 to Program Supervisor, Perla Leyvas. Per Program Supervisor, Perla Leyvas an operable Carbon Monoxide detector will be added in the classroom and a picture will be submitted to LPA Eivazian via email by plan of correction due date.

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff file review by LPA Eivazian the licensee did not comply with the section cited above in 2 out of 5 staff did not have proof of immunization against Measles (MMR) and Pertussis (TDAP) on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2023
	Plan of Correction
1 2 3 4	Per Program Supervisor, Perla Leyvas copies of proof of immunization against MMR and TDAP for staff#2 and staff#3 will be submitted to LPA Eivazian by plan of correction due date via email.

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:

Christina Gabelman

LICENSING EVALUATOR NAME:

Anomeh Eivazian

LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 01/17/2023 12:03 PM - It Cannot Be Edited

Created By: Anomeh Eivazian On 01/17/2023 at 11:25 AM

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: COLUMBUS STATE PRESCHOOL	FACILITY NUMBER: 198006185
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.16(a)(1)

(a) (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
1 2 3 4	Based on file review and program supervisor, Perla Leyvas, the licensee did not comply with the section cited above and did not complete Water Lead Testing or request for waiver at this time which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2023
	Plan of Correction
1 2 3 4	Per Program Supervisor, Perla Leyvas children do not use water faucet for drinking. Facility provides water bottles to children for drinking. During this inspection LPA observed water faucet in the classroom was accessible to the children. Per Program Supervisor, Perla Leyvas they will submit a waiver not to complete water lead testing at this time.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Christina Gabelman

LICENSING EVALUATOR NAME:

Anomeh Eivazian

LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

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