198009062-5-20-2022-30-CC-DADS-CELRFY-20220520125951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198009062
Report Date: 05/19/2022
Date Signed: 05/20/2022 01:04:06 PM

Document Has Been Signed on 05/20/2022 01:04 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	BURBANK EDUCARE PRESCHOOL		FACILITY NUMBER:	198009062
ADMINISTRATOR:	MARY OLIVELLE		FACILITY TYPE:	850
ADDRESS:	1709 W VICTORY BLVD		TELEPHONE:	(818) 845-1833
CITY:	BURBANK	STATE: CA	ZIP CODE:	91506
CAPACITY:	35	CENSUS: 26	DATE:	05/19/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Director, Marie Olivelle		TIME COMPLETED:	04:30 PM

NARRATIVE

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On 5/19/2022 at 10:40 am Licensing Program Analysts (LPA) Dalicia Adkins arrived at Burbank Educare Preschool to conduct an un-announced case management visit to follow up on an Unusual Incident that occurred at the facility on Friday April 15, 2022. LPA met with Director Marie Olivelle, LPA informed director about the purpose of the visit. Director provided LPA with a tour of the facility. LPA observed 5 staff: 1 Director and 4 teachers. There were 26 children present.

On 5/9/2022 Director, Marie Olivelle called licensing to report a self reported unusual incident that occurred on 4/15/2022. C1 was running on the playground, C1 fell and sustained injury to arm/wrist. It was reported that no other children or staff was involved resulting in C1 falling.

LPA Adkins conducted classroom observations, interviewed staff and collected the following records: Children’s Roster, Copy, Activity Schedule and Teacher Roster. LPA Adkins took pictures of play yard.

Based on interviews, record reviews, and observations it was determined that this incident needs to be further investigated.

It was determined that licensee did not report incident that occurred on April 15, 2022 to licensing within next close of next business day as required by licensing. LPA confirmed with licensee that C1 was injured at the facility resulting in need of medical treatment.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (424) -30-3038
LICENSING EVALUATOR NAME: Dalicia Adkins	TELEPHONE: (424) 301-3064
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: BURBANK EDUCARE PRESCHOOL	FACILITY NUMBER: 198009062
	VISIT DATE: 05/19/2022

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LPA confirmed with licensee that the unusual incident occurred on 4/15/2022, this incident reported to licensing on 5/9/2022. This is a violation of Title 22 Regulations, Reporting Requirements 101212. Any injury to any child that requires medical treatment a report shall be made to the Department by telephone or fax within the Department’s next working day and during its normal business hours. In accordance with California Code of Child Care Title 22 Division 12 Chapter 1 this facility is cited (1) deficiency, this is a type B citation.

Refer to LIC D.

Licensee agrees to submit LIC 855 declaration to LPA Adkins via email by 5/23/22. Licensee will demonstrating in writing how to meet licensing requirements standards and how these standards will be adhered to.

This report reviewed with licensee and Exit interview conducted.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (424) -30-3038
LICENSING EVALUATOR NAME: Dalicia Adkins	TELEPHONE: (424) 301-3064
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/20/2022 01:04 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: BURBANK EDUCARE PRESCHOOL	FACILITY NUMBER: 198009062
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/19/2022 Section Cited	1 2 3 4 5 6 7	101212 Reporting Requirements (d) Upon the occurrence, during a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report... Department within seven days following the occurrence of such event. (1) (B) Any injury to any child that requires medical treatment. This requirement is is not met by evidence by:
	8 9 10 11 12 13 14	LPA confirmed with licensee that the unusual incident occurred on 4/15/2022, this incident reported to licensing on 5/9/2022. This is poses a potential health and safety risk to children in care.	8 9 10 11 12 13 14
	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: Karren Starks	TELEPHONE: (424) -30-3038
LICENSING EVALUATOR NAME: Dalicia Adkins	TELEPHONE: (424) 301-3064
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC809 (FAS) - (06/04)

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