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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015952
Report Date: 08/31/2022
Date Signed: 08/31/2022 01:08:42 PM


Document Has Been Signed on 08/31/2022 01:08 PM - 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 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: 31DATE:
08/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Director Renee KoskaTIME COMPLETED:
01:15 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
On 8/31/22 Licensing Program Analysts (LPAs) Jeanette Estrada and Austin Estrada conducted an unannounced required 1 year inspection. LPAs met with Director Renee Koska and informed her of the purpose of the visit. LPAs provided Facility Entrance Checklist to Director. The facility was observed to be within the license capacity and limitations. Upon arrival there were nine children with three staff in the gross motor class-Room 11, eight children with three staff in the fine motor class-Room 13, six children with four staff in the cognitive class-Room 14, and eight children with one staff in the language classroom-Room 15. Criminal Record Clearances for staff present was verified. Operating hours are Monday, Wednesday and Friday 9 AM to 12 PM. The facility provides services to children ages 2 to entry into first grade.
This is a full inclusion center based program. Children are grouped according to their developmental levels. The groups rotate among the classrooms throughout the session. Classrooms used in the facility are 11, 13, 14 and 15 and the snack room.
All areas on the facility sketch were inspected. Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. There is cental air/heating in the facility. Children have their own cubbies in the hallway to store their belongings. The main office is used as the isolation area for ill children waiting to be picked up. The isolation restroom is the staff restroom in the hall way. There are two restrooms available for children in the facility. The main restroom has 2 toilets and 2 sinks and the second restroom has 3 toilets and 2 sinks General sanitation was observed in the children's restrooms. The facility offers potty training. There is a changing table in each restroom.
Availability of indoor drinking water was observed in classrooms via water bottles. Per Director, disposable cups are used and staff assist children if needed. Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Cleaning supplies are stored in shelves above the sinks. Medication is stored in the refrigerator if needed and in a locked box in the main office. Per Director, children enrolled do not require medication during the hours they are present. Poisons are stored in the Director's office. There is at least one operable carbon monoxide detector in the facility. The facility has a central fire alarm installed. Each class contains a first aid kit. First aid kit were inventoried.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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 5


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: BETHANY MANOR DEVELOPMENT AND LEARNING CENTER
FACILITY NUMBER: 198015952
VISIT DATE: 08/31/2022
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
26
27
28
29
30
31
32
Page 2
Per Facility Representative there are no firearms stored on the premises. There are no pools or bodies of water at the facility. There is a 2A10BC fire extinguisher in each classroom. Fire extinguishers were last serviced in 12/2021. There is no nap time offered due to this being a half day program.
Children’s Records were reviewed for completeness. Child 1 was missing LIC 702-Physician's report.
Staff files were also reviewed. Staff 1- 6 did not have a Mandated Reporter training certificate on file, Staff 5 did not have a TB clearance on file and Staff 7 & 8 did not have proof of Measles immunization on file.
Children's roster was reviewed and is current. Sign-In and Sign-Out sheets were reviewed. A disaster drill log was available. Last drill documented was held on 8/10/22
Parents provide snack for children due to dietary restrictions and the facility also has snack items available if needed. Menus are provided to parents/ authorized representatives one month in advance and the menus are also posted. Menus for the past 30 days are available upon request.
All food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids or solid waste bags shall be discarded immediately after each meal. Currently there are four children enrolled with food allergies. A food allergy list is posted in the snack room.
The outdoor playground area was evaluated. The outdoor playground is fully fenced. Outdoor equipment is in a safe condition, free of sharp, loose or pointed parts. All areas around or under high climbing equipment and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard. There is a play structure in the play yard. Per Director, the program mainly uses the Gross Motor Classroom-room 11, for gross motor activities.
Incidental Medical Services (IMS) policy was discussed. There are no children currently enrolled who require medication at the facility. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: BETHANY MANOR DEVELOPMENT AND LEARNING CENTER
FACILITY NUMBER: 198015952
VISIT DATE: 08/31/2022
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
26
27
28
29
30
31
32
Page 3
Facility Representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
LPA advised the licensee/facility representative how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the
inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/tion-process.

The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-Ds for Type B citations. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and Appeal Rights and report were reviewed with Director Renee Koska .

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/31/2022 01:08 PM - It Cannot Be Edited

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: BETHANY MANOR DEVELOPMENT AND LEARNING CENTER
FACILITY NUMBER: 198015952

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 staff who did not have proof of required measle immunization on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
1
2
3
4
Director will obtain proof of immunization vaccine for measles for staff 7 and staff 8. Director will submit proof to LPA via photo.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 6 staff who did not have a mandated reporter training certificate on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
1
2
3
4
Director will have staff 1 - 6 complete the mandated reporter training-general and child care provider training and will submit the certificates to LPA via photo. Director was advised training can be accessed on www.mandatedereporterca.com and shall be renewed every 2 years.

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: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/31/2022 01:08 PM - It Cannot Be Edited

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: BETHANY MANOR DEVELOPMENT AND LEARNING CENTER
FACILITY NUMBER: 198015952

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one staff file which did not contain proof of TB clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
1
2
3
4
Director will obtain proof of TB clearance for staff 5 and will submit proof to LPA via photo.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one child's file which did not contain a completed physician's form LIC 702 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
1
2
3
4
Director will have parent or authorized representative of Child 1 obtain a physician's report which includes a tuberculosis clearance. LIC 702 must be completed by a physician. Director will submit photo to LPA

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: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5