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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019207
Report Date: 10/26/2021
Date Signed: 10/26/2021 12:09:25 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:BUSHNELL WAY ELEMENTARYFACILITY NUMBER:
198019207
ADMINISTRATOR:LILIANA NARVAEZFACILITY TYPE:
850
ADDRESS:5507 BUSHNELL WAYTELEPHONE:
(323) 255-6511
CITY:LOS ANGELESSTATE: CAZIP CODE:
90042
CAPACITY:20CENSUS: 9DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Liliana Narvaez, PrincipalTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Mireya Garcia conducted an unannounced annual inspection. Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPA met with Liliana Narvaez, Principal, who guided analyst on a tour of the facility. This is an LAUSD state preschool program located in RM K2 on the premises of Bushnell Way Elementary School. The program consists of 1 classroom; Room K2. Facility operation hours are Monday through Friday from 7:45 AM to 2:15 PM.

All areas identified on the Facility Sketch were inspected. Upon arrival, the following staff were present during this inspection: Staff #1, #2 and #3 with 9 preschoolers. The following was observed during the tour of the facility:



PHYSICAL PLANT
Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubby to store their belongings. Per Principal, the isolation area is located in the outdoor canopy adjacent to the auditorium. In addition, quarantine room is available in the computer lab which is used only for quarantine purposes. In the canopy a chair is available for an ill child and in the quarantine room a cot is available. There is a restroom that is readily available if an ill child requires it. -------Report continues on next page 1 of 4
SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya GarciaTELEPHONE: (323) 981-3390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 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: BUSHNELL WAY ELEMENTARY
FACILITY NUMBER: 198019207
VISIT DATE: 10/26/2021
NARRATIVE
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Age appropriate sinks and toilets were inspected for availability and good repair in the restroom. LPA observed that the classroom has carbon monoxide detector which was tested and is in operable condition. General sanitation was observed. Availability of indoor water bottles was observed inside classroom.

Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children in all areas. Principal states that there are no poisons stored at the facility.

All kitchen areas/food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. There are no trash cans with tight fitting lids in the classrooms. However, Teacher states that on rainy days children have meals inside classroom and trash is placed in movable bin with tight fitting lid which was observed outside classroom.

Outdoor playground equipment is in safe condition, free of sharp, loose or pointed parts. LPA Garcia advised Principal that the children need to be within the direct care and supervision, including visual supervision, of the teacher(s) and supervising staff at all times. There is adequate shade in the play yard. Per Principal, children take their water bottles outside during outdoor play.

FACILITY RECORDS: All individuals present have obtained a criminal record clearance or criminal record exemption. All staff have received an active criminal record clearance as a condition of their employment with the Los Angeles Unified School District. There is at least one person trained in CPR and Pediatric First Aid present during this inspection. -------Report continues on next page 2 of 4

SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya GarciaTELEPHONE: (323) 981-3390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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: BUSHNELL WAY ELEMENTARY
FACILITY NUMBER: 198019207
VISIT DATE: 10/26/2021
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Children’s Records were reviewed for completeness; Inspection of required forms was made. LPA Garcia issued the Children’s Record Review (LIC 857) to the Principal during this inspection. In review of children’s records, files contain information including, but not limited to the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary.

LPA Garcia did not review staff files during the inspection due to the staff files being stored at the administrative office. LPA will review staff files at a later time and date. If staff files were to be incomplete during the time and date that LPA reviews files, a case management inspection will occur at the facility to reflect the incomplete files.

LPA Garcia also issued the Confidential Names List (LIC 811) to the Principal during this inspection. The LIC 857 and the LIC 811 documents the staff names recorded and children’s files that were reviewed during this inspection.

Children's roster was reviewed and is current. Sign-In and Sign-Out sheets were reviewed. Children present were signed in. Disaster drill log was available, last drill was conducted on 10/21/21.

Food Menus are 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. Preschoolers are provided with breakfast, lunch, snack and supper bag to go by the Los Angeles Unified School District.

-------Report continues on next page 3 of 4

SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya GarciaTELEPHONE: (323) 981-3390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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: BUSHNELL WAY ELEMENTARY
FACILITY NUMBER: 198019207
VISIT DATE: 10/26/2021
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First Aid supplies were observed in the classroom stored inside a cabinet. According to the Office Manager, medication is only administered to a child when accompanied with a doctor's note. Medication is stored in the elementary school’s nurse’s office and the school nurse and office personnel administers the medications which are stored in a locked cabinet.

Medication: This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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 advised the Principal to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

At this time, there were no deficiencies cited during today’s inspection.

A notice of site visit was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with facility representative, Liliana Narvaez.


Page 4 of 4 End of Report---------------------------
SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Mireya GarciaTELEPHONE: (323) 981-3390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4