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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015952
Report Date: 07/26/2019
Date Signed: 07/26/2019 10:44:44 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:BETHANY MANOR DEVELOPMENT AND LEARNING CENTERFACILITY NUMBER:
198015952
ADMINISTRATOR:RENEE KOSKAFACILITY TYPE:
850
ADDRESS:15415 S. PIONEER BLVD.TELEPHONE:
(562) 868-1517
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:64CENSUS: 8DATE:
07/26/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Elsa Moreno, Teacher
Gloria Martinez, Teacher
Leena Willis, Teacher		TIME COMPLETED:
09:45 AM
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An unannounced Case Management Inspection was conducted on this day by Licensing Program Analysts (LPAs) A. Lucero and F. Vasquez to address an Unusual Incident Report that was received in the licensing office on 07/11/2019. LPA met with Teacher Elsa Morena who guided LPAs on an indoor and outdoor tour of the facility as Director Renee Koska was out for the day. Teacher Gloria Martinez arrived at 9:06am to relieve teacher Elsa Moreno and to continue inspection with LPAs. At 9:21am, Teacher Leena Willis arrived to relieve teacher Gloria Martinez and to finish inspection with LPAs. The facility operates Monday, Wednesday and Friday from 9:00am to 12:00 noon.

The Unusual Incident Report (UIR) dated 7/10/19 stated that child #1 lost their balance while using a walker as they were exiting the restroom. The child tumbled to the ground and staff #1 noticed the child bleeding from the chin as staff #1 was picking up child from the ground where they fell. First aid was administered to the child. Child's representative was contacted, and child was taken to urgent care where child received stitches. Child returned to school on July 15, 2019. LPAs obtained sign-in/out sheet, incident report for facility, Ouch Report given to child's representative, and a copy of teacher's statement of the incident.

Based on all information obtained on this date, and interviews conducted with teachers, no follow-up is necessary regarding the incident. The incident appears to be an unusual accident. It appears to be nothing the facility staff could have done to prevent the incident from occurring. There were no deficiencies observed in regards to today's visit.

Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty.

Exit interview, copy of report was given. Appeal rights were issued and discussed.
SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J LuceroTELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2019
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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