198013498-2-18-2020-33-CC-JHUA-BLWU9F-20200218142305

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198013498
Report Date: 02/18/2020
Date Signed: 02/18/2020 02:23:09 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	PALM ELEMENTARY SCHOOL		FACILITY NUMBER:	198013498
ADMINISTRATOR:	LORI CHIMBEROFF		FACILITY TYPE:	850
ADDRESS:	14740 E. PALM AVENUE		TELEPHONE:	(626) 933-7401
CITY:	HACIENDA HEIGHTS	STATE: CA	ZIP CODE:	91745
CAPACITY:	22	CENSUS: 15	DATE:	02/18/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Lori Chimberoff		TIME COMPLETED:	02:30 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	An unannounced annual site inspection was conducted by Licensing Program Analyst, Jennifer Hua, who met with Teachers, Lori Chimberoff and Liz Garcia, who guided analyst on a complete tour of the facility. The program is located on the premise of Palm Elementary School in Room P3. The program has an AM session and PM session. AM session 8:15am -11:15am and PM session is 12:30-3:30pm. Rooms identified on facility sketch were inspected Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Storage for children's belongings and an isolation area with a sink, and toilet was inspected. Age appropriate sinks and toilets were inspected for availability and good repair. General sanitation was observed. Availability of indoor drinking water was observed. Outdoor area and equipment was inspected for safety, cushioning material, good repair and age appropriateness. Required shade, drinking water and fencing were inspected. Play area was inspected for hazards and inaccessibility to bodies of water. Playground is shared with Kindergarten. Waiver on file. Snack menus were reviewed. Food is provided by school's cafeteria daily. Teacher child ratios were observed and staff names recorded. Care and supervision was evaluated to determine if the basic needs of children are met. Report continues to 809C.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer Hua	TELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

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: PALM ELEMENTARY SCHOOL	FACILITY NUMBER: 198013498
	VISIT DATE: 02/18/2020

NARRATIVE

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Staff and children records were reviewed for completeness including but not limited teacher qualifications and verification of CPR/First Aid and health preventive practices documentation. Review of required forms was made. School district staff have background clearance as contingent of employment. Staff have completed the mandated reporter training. Certificate in file.

Staff will obtain copy of measles (MMR) record and place copy in file.

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

After a complete inspection of the facility, no deficiency cited.

This facility provides Incidental Medical Services - IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children's, personnel, and administrative records. 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 IMS not provided at this time.

An exit interview conducted with teacher Lori, copy of report given. Notice of Site Visit form provided and explained.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer Hua	TELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

LIC809 (FAS) - (06/04)

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