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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198016502
Report Date: 03/03/2022
Date Signed: 03/03/2022 10:59:49 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2022 and conducted by Evaluator Bardo Baluyot
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20220207154404
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: 2DATE:
03/03/2022
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Director Samantha MontesTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Uncleared adult worked at the day care
INVESTIGATION FINDINGS:
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At approximately 8:30 AM, Licensing Program Analyst (LPA) Bardo Baluyot conducted an unannounced follow up inspection to present findings on the complaint allegation listed above. A COVID-19 risk assessment was conducted upon entering the facility. LPA met with Teacher, Cathy Brooks until Director Samantha Montes, arrived a short time later and guided the LPA on a tour of the facility. LPA observed 2 children present with 2 staff. Required staff to children ratio was observed.

LPA interviewed the Director regarding the above allegations on 2/9/22 during the initial complaint visit. Although the complaint was submitted anonymously, Director Montes stated she was aware of who RP is/was as there was only one staff member dismissed within the last year with a pending clearance issue. Director also provided documents, including, facility roster, letter of termination for assumed RP. LPA reviewed assumed RP’s file which included resume, timesheet (10/18/21-12/15/21), LIVE SCAN form (LIC 9163) during LPA’s initial visit.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 33-CC-20220207154404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BEYOND THE CLASSROOM, INC.
FACILITY NUMBER: 198016502
VISIT DATE: 03/03/2022
NARRATIVE
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This agency has investigated the complaint alleging that an “Uncleared adult worked at the day care”. Allegation regarding “Uncleared adult worked at the day care”: According to the allegation, “RP worked at this day care from October 8, 2021 to December 15, 2021. RP stated that criminal record clearance was never granted as the status was pending while working as an Associate Teacher." Director Montes was forthcoming and confirmed the allegation.

Based on information obtained through the interview along with corroborating documents provided by the director, this agency has investigated the complaint alleging “Uncleared adult worked at the day care” and have found that the the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 & Chapter Number 1), are being cited on the attached LIC. 9099D. A Type A citation and a civil penalty was issued during today’s inspection.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Director, Samantha Montes, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 33-CC-20220207154404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BEYOND THE CLASSROOM, INC.
FACILITY NUMBER: 198016502
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2022
Section Cited
CCR
101216(i)(1)
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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department
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Director provided a signed statement that she will ensure that all newly hired staff obtain a California clearance or criminal record exemption prior to working at the facility.
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This requirement was not met as evidenced by Director’s own admission and RP’s timesheet dated 10/18/21 -12/15/21. This is an immediate risk to the health and safety of children in care. Civil Penalties are being assessed.
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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: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5