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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198008821
Report Date: 07/20/2021
Date Signed: 07/20/2021 10:30:18 AM

Document Has Been Signed on 07/20/2021 10:30 AM - 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:AMISTAD PRESCHOOLFACILITY NUMBER:
198008821
ADMINISTRATOR:ANAHIT SHMAVONYANFACILITY TYPE:
850
ADDRESS:2037 N. LINCOLN PARK AVE.TELEPHONE:
(323) 441-8718
CITY:LOS ANGELESSTATE: CAZIP CODE:
90031
CAPACITY: 48TOTAL ENROLLED CHILDREN: 0CENSUS: 11DATE:
07/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Site Supervisor, Anahit ShmavonyanTIME COMPLETED:
10:00 AM
NARRATIVE
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On July 20, 2021 at 9:30 a.m., Licensing Program Analyst (LPA) Mireya García, contacted Site Supervisor, Anahit Shmavonyan, via telephone due to COVID-19 and precautionary measures in order to conduct a Case Management inspection. At 9:49 a.m., the call was transferred into a FaceTime tele-inspection. LPA García discussed the purpose of the call. During this tele-inspection the Site Supervisor took this LPA on a virtual tour of the facility. There were 11 children observed to be present at the facility during this tele-inspection.

During interviews conducted with staff, disclosures were made regarding a Personal Rights violation conducted by Staff #1. Disclosures indicated that Staff #1 forced children to use the restroom even when they did not need to use restroom. More than one (1) Staff confirmed this information. This poses a potential health and safety risk to children in care. Title 22 Regulation Section 101223 Personal Rights states (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.



REPORT CONTINUES ON NEXT PAGE 1 OF 2.
Brandi VanOosten
Mireya Garcia
DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2021
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: AMISTAD PRESCHOOL
FACILITY NUMBER: 198008821
VISIT DATE: 07/20/2021
NARRATIVE
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The deficiency listed on the following pages is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809d. Deficiency that is being cited needs to be cleared to protect the children’s health & safety.

Exit interview was conducted with Site Supervisor, Anahit Shmavonyan via tele-inspection, during which Appeal Rights were verbally explained to Site Supervisor. A copy of this report has been signed by LPA García. This report, along with a copy of the Appeal Rights (LIC 9058) will be scanned via e-mail to Site Supervisor, Anahit Shmavonyan, who understands that an electronic “Read Receipt” and/or confirmation of receipt of the e-mail confirms receipt of the report and constitutes an electronic signature. The facility representative was provided with the mailing address to the Monterey Park Regional Office (1000 Corporate Center Drive, Suite 200B, Monterey Park, CA 91754) and agrees to send a copy of the signed LIC 809 reports by email to LPA and mail originals forms to the office.



END OF REPORT: PAGE 2 OF 2.
SUPERVISOR'S NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2021 10:30 AM - It Cannot Be Edited


Created By: Mireya Garcia On 07/20/2021 at 10:10 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: AMISTAD PRESCHOOL
FACILITY NUMBER: 198008821

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2021
Section Cited

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Personal Rights: (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidenced by:
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LPAs interviews conducted with staff reveal, disclosures were made regarding a Personal Rights violation conducted by Staff #1. Disclosures indicated that Staff #1 forced children to use the restroom even when they did not need to use restroom. This poses a potential health and safety risk to children in care.
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In addition, staff will provide a video written response and compliance plan. Site Supervisor will send LPA Garcia training staff agenda, sign in sheet and staff written responses/compliance plan via email by POC due date 08/10/2021.

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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:Brandi VanOosten
TELEPHONE:
LICENSING EVALUATOR NAME:Mireya Garcia
TELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2021


LIC809 (FAS) - (06/04)
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