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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016407
Report Date: 01/19/2023
Date Signed: 01/19/2023 02:46:31 PM


Document Has Been Signed on 01/19/2023 02:46 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:CII/OTIS BOOTH CDCFACILITY NUMBER:
198016407
ADMINISTRATOR:LILIANA RUBIOFACILITY TYPE:
850
ADDRESS:424 N. LAKE STREETTELEPHONE:
(213) 260-7717
CITY:LOS ANGELESSTATE: CAZIP CODE:
90028
CAPACITY:40CENSUS: 25DATE:
01/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Priscilla Almejo, Site SupervisorTIME COMPLETED:
03:00 PM
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On January 19, 2023 at 11:00 AM, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced case management inspection at the above facility. A COVID-19 risk assessment was conducted prior to entering the facility. LPA met with Site Supervisor, Priscilla Almejo who guided LPA on a tour of the facility. LPA observed 25 children in care with 6 staff.

Brief Summary of Incident: On 01/17/2023 during pick up at approximately 4:15 PM, C1's mother (Parent #1/P1) spoke with Site Supervisor and reported that on 01/12/2023 C1 was crying during pick up. Staff #1 (S1) stated that C1 fell, but C1 was stating that S1 had dropped him and the lower right side of his hip was hurting. P1 stated that she checked C1 and did not observe any marks on C1's body. P1 stated that C1 was complaining that he was hurting. P1 stated that at home C1 stated, S1 was mean. P1 asked C1 why C1 doesn't tell the other teacher. C1 stated that S1 motions that she's going to give him a shot. S1 submitted an ouch report on 01/12/2023. P1 stated to Site Supervisor that a teacher (did not specify) has spanked C1 while diaper changing.

During this investigation, LPA interviewed, staff #1 (S1), staff #2 (S2), staff #3 (S3), child #1 (C1), parent #1 (P1), obtained a copy of internal incident report and current facility roster.

Per S1, S2 and S3, they have not observed any children's right being violated at the facility. Per S1, C1 was getting on the blue bike while the class was picking up outside to return inside for pick up. Per S1, C1 was falling and S1 grabbed him by the arm before he fell. S1 stated that C1 started to cry. S2 stated she did not observe the incident but was told by S1. S2 and S3 stated that she has never seen S1 violate C1's personal rights or make gesture (motion to give him a shot) to C1. C1 stated that he fell off of the blue bike and cried.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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 2


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: CII/OTIS BOOTH CDC
FACILITY NUMBER: 198016407
VISIT DATE: 01/19/2023
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C1 did not disclose that S1 dropped him, made gestures/motions of giving him a shot or disclose that S1 has spanked him during diaper changing. LPA interviewed C2 who did not disclose any of the above, but stated that S1 and S2 were nice. C2 disclosed that C1 likes to ride the blue bike and sometimes falls. LPA interviewed P1 who stated that during pick up S1 stated that C1 had fallen from the bike. P1 stated that C1 stated S1 had dropped him. P1 stated that C1 did not have any marks/bruises and did not require medical attention. P1 stated that C1 returned to school Tuesday 01/17/2023. P1 stated that she is not going to disenroll her child as she feels that her child is safe at the facility.

There are no deficiencies being cited.

An exit interview was conducted and a copy of this report was provided to Site Supervisor, Priscilla Almejo along with Notice of Site Visit and Appeal Rights.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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