198017611-12-21-2023-33-CC-SLII-CYQUG8-20231221143355

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198017611
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:33:59 PM

Document Has Been Signed on 12/21/2023 02:33 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:	PUEBLO CHILD DEVELOPMENT, HS		FACILITY NUMBER:	198017611
ADMINISTRATOR:	KYM ALLEN		FACILITY TYPE:	830
ADDRESS:	1460 E. HOLT AVE., HS1 & HS2		TELEPHONE:	(909) 994-3796
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY:	16	CENSUS: 1	DATE:	12/21/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Facilities planner supervisor-Kym Allen		TIME COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Cynthia Reyes and Stephanie Li conducted a case management inspection due to an incident that came into the office on 10/12/23 and incident occurred on 10/09/2023. LPAs met with Facilities planner supervisor Kym Allen. Kym Allen guided the analyst on a tour of the facility inside and out. LPAs observed that there was 1 toddler child and 2 teachers present during the time of inspection.

LPAs conducted interviews with staff, made observations by touring the facility. LPA's observed that the spring was removed from the door and tested to see if it swings back. LPA's observe door does not move when opened, door stays at position where left.

The incident that occurred on 10/09/2023 is regarding staff #1 who had her finger smashed from the front door while trying to hold the door open for parents. Per interviews with staff, maintenance came to the classroom the next day of incident and removed the spring from the door, removing the hazard from the door.

Today is the last day of class for winter break. Classroom will be closed until Jan 7th. Children will return January 8th. Per Kym Allen, the previous spring on door was outdated. He has ordered a new part and when parts arrive, new spring will be installed on door before reopening of class and children return from winter break.

The facility self reported this incident and followed all proper procedures per incident reporting. Report was sent in properly and timely.

No citations were given during his visit. Exit interview was conducted with Erika Garcia.

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Stephanie Li	TELEPHONE: (626) 366-3362
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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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