198016871-9-10-2024-33-CC-SLII-D8YUAS-20240910152514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198016871
Report Date: 09/10/2024
Date Signed: 09/10/2024 03:31:32 PM

Document Has Been Signed on 09/10/2024 03:31 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	MCKINLEY MONTESSORI ACADEMY		FACILITY NUMBER:	198016871
ADMINISTRATOR:	RACHEL CORDOVA		FACILITY TYPE:	850
ADDRESS:	217 E. MCKINLEY AVENUE		TELEPHONE:	(909) 620-8400
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY:	75	CENSUS: 0	DATE:	09/10/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Director Rachel Cordova		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Stephanie Li conducted an unannounced Case Management inspection due to an incident that occurred on 9/5/24 and was reported to the Department on 9/6/24. A COVID risk assessment was conducted. LPA met with Director Rachel Cordova to whom the reason for the visit was explained. Director guided LPA on a tour of the facility. There were 0 children present as center was having a staff meeting today and children were dismissed early. 6 preschool staff were present for their staff meeting. The facility was observed to be operating within the license capacity limitations. On September 5, 2024, an unusual incident report was made to the Department regarding an observation of child’s injury at morning drop off and inconsistent statements from mother to child. Child is 4 years old and was observed to have an injury above his eye covered by a band aid. Per Director and submitted statements, Teacher 1 had asked mother what had happened, and mother stated that the child hit himself with the door and when the same question was asked of the child, he stated that his mother had hit him in the head with an object. Facility staff noted the inconsistency in statements of child’s injury and reported the incident electronically to DCFS. DCFS report #ER20240906036. Referral no. 0346-3682-7250-8070066. Due to the center’s previous incident reported on 6/17/24, LPA is reviewing facilities documentation procedures and practices. LPA observed that center has obtained a parent statement regarding the injury, teachers statement of observation and parent interaction, photo image of first page of medical report from Pomona Valley Medical center stating child has a gash in head and additional statement from mother stating child has 2 staple stitches in her head. All documents were submitted to licensing along with the LIC624.Child's file was reviewed during visit. *continued on next page

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Stephanie Li	TELEPHONE: (626) 366-3362
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MCKINLEY MONTESSORI ACADEMY	FACILITY NUMBER: 198016871
	VISIT DATE: 09/10/2024

NARRATIVE

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Medical report image states child sustained injury from a specified distance but the rest of the report was blocked by paper with mothers statement. LPA observed that medical report patient was for younger sister who sustained an injury a day after the brother. Per director, mother reported injury regarding the sister on 9/9/24. Director submitted medical report along with previous UIR. LPA advised that sisters injury needs to be reported as a separate incident report. LIC624 for sister was collected during today's visit. Per director, DCFS social worker Jacqueline Jimenez came to facility on 9/9/24, contact info was retained. When asked Director, if photos were taken, she stated no. LPA advised for facility to take pictures of injuries that are observed immediately. LPA advised director when medical reports are provided by parents to request copies of full pages and all pages of the reports to retain in child’s file. LPA reviewed facilities in house incident/injury report and advised to include a staff check off list to indicate photo captured, requires medical attention, and medical report provided.

LPA consulted with director about training staff in future training's for documenting practices, observation skills, and notifying director immediately on serious injuries. Per director, teaching staff did not notify director until the next day. LPA observed director pull teachers in and reviewed information regarding documenting practices, capturing photos and obtaining full medical reports. Director reported incident as soon as she was informed. Both incidents were reported timely.

Based on information obtained during this investigation, no additional follow up is necessary regarding the incident reported. No deficiencies are being cited at this time.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Director Rachel Cordova.

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SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Stephanie Li	TELEPHONE: (626) 366-3362
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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