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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016502
Report Date: 10/26/2021
Date Signed: 10/26/2021 02:51:44 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:BEYOND THE CLASSROOM, INC.FACILITY NUMBER:
198016502
ADMINISTRATOR:SAMANTHA MONTESFACILITY TYPE:
840
ADDRESS:304 PASADENA AVENUETELEPHONE:
(323) 449-4058
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY:60CENSUS: 16DATE:
10/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Director, Samantha MontesTIME COMPLETED:
03:00 PM
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An unannounced Case Management visit was conducted on this date by Licensing Program Analyst (LPA) Bardo Baluyot following an incident reported to CCLD on 10/18/21 involving a child who ingested hand sanitizer. LPA conducted a COVID risk assessment prior to entry. Upon arrival, LPA was greeted by Director, Samantha Montes who guided the LPA on a tour of the facility. LPA observed all staff and children wearing masks.

Census: There were 16 school age children present. Staff-child ratio was met.

During today's inspection, Director guided the LPA on a tour of the entire facility including all classrooms, restrooms and outdoor areas. Interviews were conducted with the Director (Staff #1), other teachers involved in the incident(Staff #1 & Staff #2) as well as child who ingested the hand sanitizer. LPA also obtained a current roster. Per Director, mom opted not to take child to doctor and reported that child was observed to be fine through the night and was able to return to school the following day. LPA discussed RAST guidelines and recommendations with Director and issued a Technical Advisory. Director requested for an appointment to have LPA to conduct a full RAST tele-visit at a later date for record purposes.

No deficiencies cited today and the facility is in compliance with Title 22. Upon receipt, Director Samantha Montes posted the Notice of Site Visit. The Notice of Site Visit shall be posted for thirty (30) consecutive days. Failure to maintain posting as required will result in a $100 civil penalty.

An exit interview has been conducted with, and a copy of this report has been signed by and provided to Director, Samantha Montes. Appeal Rights have been provided and explained to Director.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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