198017844-5-4-2022-33-CC-NTCG-CE4VMP-20220504163353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198017844
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:34:07 PM

Document Has Been Signed on 05/04/2022 04:34 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:	PASADENA PRESCHOOL ACADEMY		FACILITY NUMBER:	198017844
ADMINISTRATOR:	GUNASEKARA, HISSANKA		FACILITY TYPE:	830
ADDRESS:	2631 WOODLYN		TELEPHONE:	(626) 794-4614
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	32	CENSUS: 24	DATE:	05/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Arlene Madrid - Director		TIME COMPLETED:	02:04 PM

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Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced random annual inspection. Upon arrival at 11:40am, LPA met with Director Arlene Madrid. At 11:50am, Director led LPA on a tour of the facility. This is an Infant program which consists of 2 classrooms. Per licensee, there are currently 26 enrolled in the program. Hours of operation for this facility are 6:30am-6:30pm, Monday-Friday.

Licensing staff observed all required forms/publications to be posted in the office. Snack menus were reviewed to ensure that they are being posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request.

PHYSICAL PLANT: At 11:50am, LPA entered and inspected Infant Room (6weeks-14mo): 13 children with 3 staff members, and Toddler Room (15mo-23mo): 11 children with 3 staff members. Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts. All floors are clean and safe. At 11:55am, LPA observed the diaper changing table to be at least one inch thick, with raised sides of at least 3-inches, and within arms reach of the sink in the infant classroom. Cribs and napping equipment were observed in the infant program. LPA observed portable cribs that meet Consumer Product Safety Commission safety standards. Mattresses have an appropriate size mattress with a fitted sheet. Crib was observed to be free of loose items. Cots were available for infants who are able to climb out of a crib. Sleeping area is physically separated and cribs did not limit staffs ability to watch infants at all times. Per Director, bedding is changed daily. At 12pm, A fire extinguisher was observed. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 09/01/2021, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids.

REPORT CONTINUES PAGE 1 of 4

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA PRESCHOOL ACADEMY	FACILITY NUMBER: 198017844
	VISIT DATE: 05/04/2022

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The facility was observed to be free of flies, other insects and rodents. Sufficient individual storage space for children was observed and each child has a cubby. Drinking water was readily available indoors. At this time, the office is used as an isolation area. A cot is available for an ill child to rest on. Director states there is also a changing mat available for infants and staff to use for ill children. First Aid supplies are available and complete. Facility has a functioning carbon monoxide detector that meets statutory requirements. Director states there are no weapons, firearms, or bodies of water on the premises. At 12:05pm, LPA observed the kitchen section for the infant rooms. Breakfast, lunch and snack menu was observed posted for both classrooms. Food in refrigerator was labeled. Infant formula is available and Infant Needs and Service plans were reviewed on file. Kitchen counter tops were clean and free of clutter or standing food.

At 12:10pm, LPA reviewed the outdoor play area. Outdoor playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with fake grass material that absorbs a fall. There are two outside play spaces that children in care use. One area is used for small infants and has ample shade and age appropriate toys. The other outside play space observed has a small play structure and age appropriate toys and equipment. Drinking water is readily available outdoors.

Teacher-child ratios were observed to be in accordance with Title 22 regulations. Staff names were recorded. All children were observed to be under visual supervision of a teacher during tour. The Licensee is within the conditions, limitations, and capacity specified on the license. All areas were identified on the Facility Sketch were inspected.

FACILITY RECORDS: Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. Disaster drills have been conducted at least every six months. Staff files were reviewed for a health screening report and immunizations that meet regulatory requirements. Criminal Record Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed. The name of the child care center director or fully qualified teacher(s) designated to act in the director's absence is on file. Educational background, training, and/or experience for each staff present are on file and were reviewed. A random sample of Children’s Records were reviewed to ensure that they are complete

REPORT CONTINUES PAGE 2 of 4

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: PASADENA PRESCHOOL ACADEMY	FACILITY NUMBER: 198017844
	VISIT DATE: 05/04/2022

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INCIDENTAL MEDICAL SERVICES:
This facility provides Incidental Medical Services –( IMS). Facility has submitted IMS plan for all locations. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA observed masks being worn around the facility and signs regarding COVID-19 posted at the entrance and around the facility. Temperatures are being taken 3 times a day for children and upon entry for all staff.

LPA discussed the safe sleep regulations with Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

REPORT CONTINUES PAGE 3 of 4

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: PASADENA PRESCHOOL ACADEMY	FACILITY NUMBER: 198017844
	VISIT DATE: 05/04/2022

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LPA advised the licensee how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov. AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com/

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.

Exit interview was conducted with Director Arlene Madrid, at 1:55pm. Copy of report provided.

END OF REPORT PAGE 4 of 4

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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