198018769-10-25-2019-33-CC-LGOZ-BHAU3F-20191025151328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198018769
Report Date: 10/25/2019
Date Signed: 10/25/2019 03:13:33 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:	PLAZA DE LA RAZA C.D.S.- MAIZELAND		FACILITY NUMBER:	198018769
ADMINISTRATOR:	CABOT, NORAYMA		FACILITY TYPE:	830
ADDRESS:	7601 CORD AVE.		TELEPHONE:	(562) 205-2789
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY:	96	CENSUS: 50	DATE:	10/25/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Araceli Brion		TIME COMPLETED:	03:28 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) Lissete Gonzalez conducted a case management inspection due Incident #1 that occurred on 10/02/2019 and Incident #2 that occurred on 10/23/2019. LPA met with Araceli Brion, Education Coordinator, who guided LPA on a tour of the facility. Census was taken. LPA conducted interviews and obtained documentation during this visit. Incident #1 which occurred on 10/02/19 was received by the Department on 10/03/19 via telephone. The incident that occurred on 10/02/18 was received by the Department on 10/08/18 via fax. The facility reported the incident to the Department within the required 24 hours. It was reported to the Department that Child #1 pushed Child #2 resulting in Child #2 falling. During the fall, Child #2 hit a chair and sustained a welt. LPA conducted interviews with Staff #1 and Staff #2. Staff #3 was not present on this date. Based on information obtained on this date, record review, and interviews conducted, no follow-up is necessary regarding the incident. The incident appears to be an unusual incident. Facility staff could not have done anything to prevent the incident from occurring. Per California Code of Regulations Title 22, Division 12, no deficiency cited during today's visit. Incident #2 which occurred on 10/23/19 was received by the Department on 10/24/19 via telephone. The facility reported the incident to the Department within the required 24 hours. It was reported to the Department that Child #3 fell forward resulting in Child #3 hitting right cheek on a wooden table, which caused an open gash. LPA conducted interviews with Staff #2 and Staff #4 during this inspection. Staff #4 observed the incident. Based on all information obtained on this date, record review, and interviews conducted, facility staff provided medical treatment and notified parents of incident. The incident appears to be an unusual incident. Facility staff could not have done anything to prevent the incident from occurring. Per REPORT CONTINUES ON NEXT PAGE: 1 OF 2

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Lissete Gonzalez	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019

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: PLAZA DE LA RAZA C.D.S.- MAIZELAND	FACILITY NUMBER: 198018769
	VISIT DATE: 10/25/2019

NARRATIVE

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California Code of Regulations Title 22, Division 12, no deficiency cited during today's visit.

Exit interview was conducted with Education Coordinator, Araceli Brion. Appeal rights explained & provided.

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.

END OF REPORT: PAGE 1 OF 2

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Lissete Gonzalez	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019

LIC809 (FAS) - (06/04)

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