198018645-9-10-2021-33-CC-BBEL-C6QRB5-20210910125210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198018645
Report Date: 09/10/2021
Date Signed: 09/10/2021 12:52:20 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:	GANESHA HIGH CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	198018645
ADMINISTRATOR:	KYM ALLEN		FACILITY TYPE:	830
ADDRESS:	1151 FAIRPLEX DR. RM 95		TELEPHONE:	(909) 397-4914
CITY:	POMONA	STATE: CA	ZIP CODE:	91768
CAPACITY:	22	CENSUS: 6	DATE:	09/10/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Faclities and LicensingPlanner Kym Allen		TIME COMPLETED:	01:00 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	An unannounced in-person Case Management-Incident inspection was conducted on this date by Licensing Program Analyst (LPA) Emiko Bell to follow up on an Unusual Incident which occurred on 06/17/21 and was reported via email on 06/18/21 to Community Care Licensing (CCL) . LPA arrived at the facility at 10:55 am; Mr. Allen arrived at 11:20 am. At 11:20 am, Mr. Allen and LPA entered the classroom and census was taken. Census: In Ganesha 2, there were 2 staff with 4 infants; in Ganesha 1, there were 3 staff with 2 infants. Staff-child ratio was met. During the course of the investigation, interviews were conducted with two staff. The Unusual Incident which occurred is that an infant was observed to have sustained a bruise on their right ear and left buttock on a Friday. The child was not present the following Monday, but returned to care on Tuesday and missed four more days before returning. The child has not been in attendance since August 11, 2021. LPA discussed following up on Unusual Incident Reports (UIR) and providing detailed information on the written UIR (i.e. providing a follow up UIR if additional information is acquired). Additional details obtained by LPA in the future regarding this case will be documented.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

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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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: GANESHA HIGH CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 198018645
	VISIT DATE: 09/10/2021

NARRATIVE

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Upon receipt, the Notice of Site Visit was posted. The Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100 civil penalty.

An exit interview was conducted with, and a copy of the report has been signed by and provided to Faclities and LicensingPlanner Kym Allen Appeal Rights have been provided and explained to Director Fuentez as well.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC809 (FAS) - (06/04)

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