<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015336
Report Date: 09/21/2023
Date Signed: 09/21/2023 10:56:42 AM


Document Has Been Signed on 09/21/2023 10:56 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:GOLDEN SPRINGS CHILD DEVELOPMENT CENTER, RM. 29FACILITY NUMBER:
198015336
ADMINISTRATOR:KYM ALLENFACILITY TYPE:
850
ADDRESS:245 S. BALLENA DR.TELEPHONE:
(909) 806-2392
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:15CENSUS: 11DATE:
09/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Teresita Van Gordon, Erika Mendez, Mukta ChamTIME COMPLETED:
11:00 AM
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
Case management inspection conducted by Licensing Program Analyst (LPA) Jennifer Hua. The purpose of the visit is to follow up on the incident that was reported to the Department on 9/12/23. LPA arrived to the Golden Springs Elementary School office at 8:45am, and was directed to Room #29. LPA arrived to room #29 at 8:50am. LPA met with Substitute teacher Teresita Van Gordon. The purpose of the visit was announced. LPA observed 11 children in care with 2 staff. During the visit, substitute contacted their supervisor to come to the facility to assist. Coordinator Mukta Cham arrived at 9:18am along with Research Teacher, Yelena Khachatryan.

It was reported that a staff member reported that they observed another staff member violated children's personal rights on different occasions but staff does not have dates or time of incidents.

During the visit, interviews were conducted with staff, coordinator and children.

No deficiency cited at this time.

An exit interview conducted with Mukta Cham, Coordinator. Notice of Site Visit Form provided and shall be posted for 30 days.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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 1