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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198010922
Report Date: 10/26/2021
Date Signed: 10/26/2021 03:36:58 PM

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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CUDAHY PRESCHOOL ACADEMYFACILITY NUMBER:
198010922
ADMINISTRATOR:ADOL VERGARAFACILITY TYPE:
850
ADDRESS:4912 CLARA STTELEPHONE:
(323) 771-8700
CITY:CUDAHYSTATE: CAZIP CODE:
90201
CAPACITY:60CENSUS: 7DATE:
10/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Adol Vergara, DirectorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Alicia Mooberry arrived at facility to conduct an unannounced Case Management inspection for an Unusual Incident regarding child sustained injury during outdoor play activity on 10/15/21. The Monterey Park South West Child Care Regional Office received the incident report on 10/15/21.

LPA met with Adol Vergara, Director at 2:05 PM, and toured the facility. The Child Care center consists of 2 classrooms - B7 (Full day program) and B6 (Half Day program). There were 7 children and 2 staff present in Room B7 and no children present in Room B6. LPA Interviewed Director, Staff #1 and Staff #2 who were present during the incident. Child was not present and not able to be interviewed. Staff and and Child files were reviewed, and documents were obtained. LPA observed the play area where child was injured and observed to be free of hazards and the equipment is in good repair. Photos were taken of the play area and the play equipment used during activity.

Per staff interviews, on the day of the incident, there were two staff and 14 children present. Child #1 was jumping over cones set up as obstacle course, Child #1 jumped and lost footing landing on a 6 inch plastic cone and injuring their groin area. Child was provided 1st and parent was called. Child was taken to the doctor for medical attention and returned to school on 10/19/21.

Based on the information that was gathered during today's interviews, and based on LPA's observations and document review it does not appear this incident was the result of a Title 22 violation. No deficiency was cited.


An exit interview was conducted with Adol Vergara, Director. The notice of site visit must be posted for 30 days upon receipt.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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