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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198010409
Report Date: 10/26/2022
Date Signed: 10/26/2022 11:18:54 AM


Document Has Been Signed on 10/26/2022 11:18 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:SIERRA MADRE EARLY CHILDHOOD PROGRAMFACILITY NUMBER:
198010409
ADMINISTRATOR:PATRICIA GUZMANFACILITY TYPE:
850
ADDRESS:141 W. HIGHLAND AVETELEPHONE:
(626) 355-1428
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY:25CENSUS: 9DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Teacher, Xochitl BajoTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA),Bardo Baluyot conducted an unannounced Required Annual inspection on this date. Upon arrival, LPA conducted a COVID risk self-assessment and met with Pre-K Teacher, Xotchitl Bajo. LPA toured the facility. LPA observed 14 children present with 3 staff.

The preschool is located on the grounds of Sierra Madre Elementary School in classroom 127 located near the parking lot off of Auburn Ave. Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubby to store their belongings. Facility uses an ipad for parents to sign in and out. LPA observed all children present to be signed in. Per teacher, the isolation area is the nurse's office located in the elementary school or the couch area can be used as well.

Facility was inspected indoors and outdoors. Drinking water is available in the classroom via filtered water and cups. First aid kit was observed in a cabinet with a first aid warning sign. Carbon monoxide detector was observed, tested and found in operable condition. Children's restrooms were inspected. Toilets and sinks are clean and in good condition. Sufficient supplies were observed in the restroom. An Emergency Disaster Drill log is kept and shows last earthquake and fire drills were conducted on 10/20/22.

Outdoor equipment was observed to be age appropriate and in good repair. There is a shaded rest area for children. Drinking water is available in form of a water fountain. Cushioning material is in good condition and fencing was inspected and found to be secured.

The program operates Monday to Friday, 7:45-10:45 and 11:45-2:45. One meal per session is provided to children. The morning session is provided with breakfast and the afternoon session is provided with lunch from Pasadena Unified School District's food program which follows mandated Federal Food Guidelines. Meal menus, license, car seat law, parents' rights for centers, emergency disaster plan and all other posting requirements were observed.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SIERRA MADRE EARLY CHILDHOOD PROGRAM
FACILITY NUMBER: 198010409
VISIT DATE: 10/26/2022
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Currently there are no children in care who require IMS.
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

Per Ms. Bajo, this program follow's PUSD"s school age scheduled and is closed June through August for summer break.

No staff files were reviewed during today's visit. Staff files are kept at PUSD's main office located at 351 S. Hudson Ave. Pasadena, CA. 91109 (626)396-3600

After a complete inspection of the facility, no deficiencies were observed/cited in accordance with California Code of Regulations Title 22 Division 12.

Exit interview conducted and report was reviewed with the Teacher, Xotchitl Bajo.


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.

INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.



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/inspection-process.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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