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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018831
Report Date: 01/15/2020
Date Signed: 01/15/2020 01:10:02 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:PINE TREE PRESCHOOLFACILITY NUMBER:
198018831
ADMINISTRATOR:MARLENE YBARRAFACILITY TYPE:
850
ADDRESS:311 S. NORMANDIE AVE.TELEPHONE:
(213) 365-0909
CITY:LOS ANGELESSTATE: CAZIP CODE:
90020
CAPACITY:63CENSUS: 13DATE:
01/15/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gloria PortilloTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janeth Chavez conducted an unannounced case management inspection to follow up with an incident that was reported to the Department on 09/11/2019. Upon arrival, LPA met with Gloria Portillo, Director who assisted LPA with a tour of the facility. This incident was self-reported via telephone by Marlene Ybarra, the former Director of this facility.

On 09/11/19, it was reported that the Personal Rights of Child #1 were violated. This information was self-reported to the Department on 09/11/2019. The incident was not reported to the Department within the 24-hour period. This is a potential health and safety risk to children in care. The written report was received in our Department on 09/11/2019, and it was within the 7 days as required. During today’s inspection staff interviews were conducted and there were no disclosures or admissions made. Also, written declarations were obtained from staff.

Based on the information obtained during this investigation, the following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety. This incident will need further investigation.

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.

Exit interview was conducted with Gloria Portillo, Director.

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) -98-3417
LICENSING EVALUATOR NAME: Janeth ChavezTELEPHONE: (323) 981-3376
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2020
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: PINE TREE PRESCHOOL
FACILITY NUMBER: 198018831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2020
Section Cited

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Reporting Requirements
Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In
addition, a written report containing the info
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specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.***This requirement is not met as evidenced by the Director not reporting the incident on 09/9/2019 within the 24 hour period or the next business day. This is a potential H&S risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) -98-3417
LICENSING EVALUATOR NAME: Janeth ChavezTELEPHONE: (323) 981-3376
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2020
LIC809 (FAS) - (06/04)
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