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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015514
Report Date: 03/03/2020
Date Signed: 03/03/2020 12:06:14 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:BPUSD - NORTH PARK HIGH SCHOOLFACILITY NUMBER:
198015514
ADMINISTRATOR:JERRI SANDELLFACILITY TYPE:
830
ADDRESS:4600 N. BOGART AVENUETELEPHONE:
(626) 962-3311
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY:40CENSUS: 12DATE:
03/03/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Rebecca Jimenez-Barlow, Early Head Start Program ManagerTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Lissete Gonzalez and Alanna Gontarek conducted a Case Management inspection due to an incident that occurred on 02/06/2020. LPA met with Rebecca Jimenez-Barlow, Early Head Start Program Manager, who guided LPAs on a tour of the facility.

LPAs conducted interviews and obtained documentation during this visit. The incident that occurred on 02/06/20, was reported to the Department on 02/07/2020, via Fax. The facility reported the Unusual Incident to the Department within the required 24 hours of occurrence.

Information reported to the Department indicated that Staff #3 unknowingly gave child #1 the wrong bottle containing breast milk. The breast milk given to child #1 belonged to child #2.

Based upon information received from the interviews conducted it was determined that the personal rights of child #1 were violated when Staff #3 fed child #1 from the wrong bottle that contained breast milk belonging to child #2. Staff #2 handed the bottle to Staff #3 to feed child #1. This was an immediate risk to the health and safety of the infant in care.

Exit interview conducted with Rebecca Jimenez-Barlow. The Licensee was provided a copy of the appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms. Upon receipt, the Licensee shall post the Notice of Site Visit and the Licensing report. This report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100 civil penalty.

A copy of this report shall be provided to the parents/guardians of the children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parents/guardians of any children newly enrolled at the facility for the next 12 months. The LIC 9224 Acknowledgement of
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Lissete GonzalezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2020
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 3
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: BPUSD - NORTH PARK HIGH SCHOOL
FACILITY NUMBER: 198015514
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2020
Section Cited

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Personal Rights.
Each child shall be accorded safe, healthful and comfortable accommodations.
This requirement was not met as evidenced by: Staff #3 unknowingly gave child #1 the wrong bottle containing breast milk. The breast milk given to child #1 belonged to child #2. This is an immediate risk to the
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health and safety of children in care.
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children's personal rights. In addition, the individual who will be feeding the infants is responsible for preparing the infant's bottle.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Lissete GonzalezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: BPUSD - NORTH PARK HIGH SCHOOL
FACILITY NUMBER: 198015514
VISIT DATE: 03/03/2020
NARRATIVE
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Receipt of Licensing Reports must be maintained in each child's file immediately upon receipt from the parent. LPA provided Licensee with a blank copy of the LIC 9224 Acknowledgement of Receipt of Licensing Report.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Lissete GonzalezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2020
LIC809 (FAS) - (06/04)
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