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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015619
Report Date: 03/05/2020
Date Signed: 03/05/2020 11:04:14 AM

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:NORWALK-LA MIRADA USD HEAD START/STATE PS-CHAVEZFACILITY NUMBER:
198015619
ADMINISTRATOR:JACQUELINE FLIETESFACILITY TYPE:
850
ADDRESS:12110 E. WALNUT AVENUETELEPHONE:
(562) 210-4533
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:48CENSUS: 31DATE:
03/05/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Assistant DirectorTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) T. Tran conducted a Case Management inspection at the above facility to follow up on the self-reported incident that occurred on 2/14/2020. The Monterey Park South West Child Care Regional Office received the incident report on 2/14/2020.

LPA conducted files review and obtained children roster and other documents. Based on the facts presented and the information gathered on the interviews, on 02/14/2020 during dismissal time between 11:25 a.m. -11:30 a.m. center staff failed to properly supervised a child in care as a result, P1 found C1 wandered alone about 150 feet away the classroom down the street toward Walnut and Norwalk street . Child did not appear to be injured, and had no visible injuries. At this time based on the available information it appear this incident was the result of a Title 22 violation for lack of care and supervision. Type A deficiency was cited, and appeal rights was provided. Please see 809 D.

LPA discussed AB633 and informed the center director that, upon receipt of a Type A deficiency, the facility shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

The content of this report was read and discussed in detail at the time of with the noted person.

An exit interview was conducted; the notice of site visit must be posted for 30 days upon receipt.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: NORWALK-LA MIRADA USD HEAD START/STATE PS-CHAVEZ
FACILITY NUMBER: 198015619
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2020
Section Cited

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Responsibility for Providing Care and Supervision-This requirement is not met as evidenced by based on interviews, the facility failed to provide adequate care for a child in care. on 02/14/2020, about 11:25 a.m.-11:30 a.m. P1 found C1 wandered alone about 150 feet away the classroom down the street toward Walnut and Norwalk street.

which poses a potential health and safety risk to children in care.



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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: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2020
LIC809 (FAS) - (06/04)
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