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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019444
Report Date: 03/25/2022
Date Signed: 03/25/2022 03:54:45 PM


Document Has Been Signed on 03/25/2022 03:54 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 CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:ANNALEE AVE ELEMENTARY PRESCHOOLFACILITY NUMBER:
198019444
ADMINISTRATOR:INGRID BRYANFACILITY TYPE:
850
ADDRESS:19410 ANNALEE AVETELEPHONE:
(310) 537-4740
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:22CENSUS: 12DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ingrid Bryant, Facility RepresentativeTIME COMPLETED:
04:14 PM
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 3/25/22 at 1:30 PM. LPA met with Ingrid Bryant, Facility Representative (FR) who guided analysts on a tour of the facility.

There were 12 children and three staff present when LPA arrived. This is a preschool program that operates a full day program on the Annalee Elementary campus in Room #K3 from 8AM to 2:30PM. All individuals present have obtained a criminal record clearance or criminal record exemption as a condition of employment with the Los Angeles Unified School District.

LPA observed required posted documentation located in the classroom, which included, Facility License, Publication (PUB) 393- Notification of Parent Rights, Licensing Form (LIC) 610- Facility Disaster Plan, PUB 269- Child Passenger Restraint System and LIC 613A- Notification of Parent’s Rights and cafeteria Menu. All documents discussed and provided to FR.

LPA toured Classroom (K3). LPA observed that furniture and equipment is maintained in good condition, free of loose, sharp and/or pointed parts. The floors of the classroom have surfaces that are safe and clean. Drinking water is made readily available for the children via individual water bottles provided by the facility. Per Classroom Teacher no cleaning supplies are stored in the classroom. Facility has smoke/carbon monoxide detectors and fire extinguishers that are routinely serviced by the fire department. Per FR, there are no children currently on medication. LPA did not observe napping equipment, per Staff children have quiet/rest time at their desks.

LPA toured the children’s restroom. Restroom was observed to be sanitary and free of hazards. Restroom is located in the preschool classroom, used only for the preschool children.
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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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 6


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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: ANNALEE AVE ELEMENTARY PRESCHOOL
FACILITY NUMBER: 198019444
VISIT DATE: 03/25/2022
NARRATIVE
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LPA toured the outdoor play area. The outdoor space is free of hazards. Outdoor space has various areas of shade for children to play. Water is readily available to children via individual water bottles and water fountain. There are no pools, spas, or other bodies of water on school grounds. There are no firearms or weapons stored at the facility.

Sign In/Out sheets located in the classroom. Due to COVID-19 precautions parents do not enter the facility, the teacher who receives the child is signing the child in and the parent signs them out at the end of the day. All children present were signed in with date, time and full signature of guardian.

Facility records were reviewed for LIC 9040- Facility Roster, 9148- Earthquake Preparedness form, Daily schedule and Disaster drill log, last drill conducted on 3/25/22.

Children’s records were reviewed for Emergency Card, Immunization Records, LIC 995 Notification of Parents’ Rights, LIC 701- Physician’s Report, LIC 613A- Personal Rights, and signed Admissions Agreement. All children's records were complete.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, Licensing Form (LIC) 9052- Employee Rights, Proof of immunization's against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse, Transcripts or Permit for qualified teacher and current Mandated Reporter Training Certificate (AB1207). LPA observed missing documents including AB1207, immunization records, TB clearance and current CPR and first aid. Other documents were discussed.

Facility provides AM snack, PM snack and lunch. Food is not cooked at the facility. Prepackaged food is delivered daily. Kitchen was observed to be clean, free of litter, insects and rodents. LPA observed trash cans for solid waste have tight fitting lids. Cleaning supplies are stored separate from the food.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: ANNALEE AVE ELEMENTARY PRESCHOOL
FACILITY NUMBER: 198019444
VISIT DATE: 03/25/2022
NARRATIVE
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LPA observed that facility is implementing COVID-19 precautions and procedures as required by Los Angeles Unified School District and the Department of Public Health.

Incidental Medical Services (IMS):
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a plan for providing IMS must be submitted to the Department. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (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

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.

Facility representative was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

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

Exit interview conducted and report was reviewed with the Facility Representative Ingrid Bryant.




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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/25/2022 03:54 PM - It Cannot Be Edited

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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: ANNALEE AVE ELEMENTARY PRESCHOOL
FACILITY NUMBER: 198019444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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Per FR they will have staff bring in proof of immunization and TB within two weeks and email to LPA by POC date
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out 3 staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
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Per FR, staff have taken this training, they will send certificates to LPA POC date.

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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 03/25/2022 03:54 PM - It Cannot Be Edited

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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: ANNALEE AVE ELEMENTARY PRESCHOOL
FACILITY NUMBER: 198019444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in3 out of 3 staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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Per FR, they will have at least one staff update their first aid and CRP and email proof to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6