198013779-1-28-2020-33-CC-LGOZ-BL9SBX-20200128124440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198013779
Report Date: 01/28/2020
Date Signed: 01/28/2020 12:44:46 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:	EL MONTE CITY SCHOOL DISTRICT-GIDLEY (HEAD START)		FACILITY NUMBER:	198013779
ADMINISTRATOR:	LISA DUNBAR		FACILITY TYPE:	850
ADDRESS:	10226 E. LOWER AZUSA AVENUE		TELEPHONE:	(626) 455-0962
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91731
CAPACITY:	25	CENSUS: 18	DATE:	01/28/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Carmelita Gonzalez, Lead Teacher		TIME COMPLETED:	01:00 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	Licensing Program Analysts (LPAs) Lissete Gonzalez and Alanna Gontarek conducted a Case Management inspection to follow up on two incidents that occurred on 9/18/2019 and 10/01/2019. Upon arrival, LPAs met with Lead Teacher, Carmelita Gonzalez, who guided LPAs on a tour of the facility. Census was taken. The incident that occurred on 9/18/2019 was faxed to the Department on 9/19/19. The facility reported the incident to the Department within the required 24 hours. LPAs conducted interviews and obtained documentation during this visit. It was reported to the Department that Child #1 picked up a chair and threw it at the teacher bruising her right upper leg. During interviews with Staff #1, Staff #2, it was disclosed that Child #1 is receiving various services to address behavioral concerns and Staff members were provided with strategies to support the child. In addition, Staff #2 did not require any medical attention. Based on all information obtained on this date, record review, and interviews conducted, LPA determined there was adequate supervision provided and timely measures were taken to work with Child #1. With regard to the incident that occurred on 10/01/2019 was faxed to the Department on 10/02/19. The facility reported the incident to the Department within the required 24 hours. LPAS conducted interviews and obtained documentation during this visit. It was reported to the Department that Child #2 attempted to hit other children and hit Staff #4 with his fist in her stomach. An interview was conducted with Staff #3 (Staff #4 was not available on this date). During the interview it was disclosed that Child #2 is received various services to address behavioral concerns and staff members implemented strategies to support the Child #2. In addition, Child #2 transferred to Head Start’s REPORT CONTINUES ON NEXT PAGE: 1 OF 2

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Lissete Gonzalez	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: EL MONTE CITY SCHOOL DISTRICT-GIDLEY (HEAD START)	FACILITY NUMBER: 198013779
	VISIT DATE: 01/28/2020

NARRATIVE

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Home Base program on 11/01/2019.

Based on all information obtained on this date, record review, and interviews conducted, LPA determined there was adequate supervision provided the day of the incident and timely measures were taken to work with Child #2.

Per California Code of Regulations Title 22, Division 12, no deficiency cited during today's visit.

Exit interview was conducted with Lead Teacher, Carmelita Gonzalez. Appeal rights explained & provided.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

END OF REPORT: PAGE 3 OF 3

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Lissete Gonzalez	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2