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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019478
Report Date: 12/17/2019
Date Signed: 12/17/2019 01:20:21 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:PUENTE AVE PRESCHOOL INFANT CARE CENTERFACILITY NUMBER:
198019478
ADMINISTRATOR:KIMBERLY NGUYENFACILITY TYPE:
830
ADDRESS:14032 DILLERDALE AVETELEPHONE:
(626) 338-3464
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY:30CENSUS: 14DATE:
12/17/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Kimberly Nguyen TIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Judy Mora conducted an unannounced Case Management inspection on this day. LPA met with Director, Kimberly Nguyen, who guided analyst on a tour of the facility.

The purpose of this visit was to ensure that the Licensee is in compliance with Title 22 regulations.

At the time of arrival to Infant Room A & B, LPA observed 02 staff with 03 infants on the A side and 4 infants on the B side with no staff. LPA then observed a teacher walk to the B side. This was an immediate risk to the health and safety of infants, as no staff were visually observing nor supervising these infants at the time.

Upon receipt of this report, the licensee shall post ANY licensing report documenting a type “A” citation. This must remain posted for 30 days during hours of operation. In addition to posting this report, the licensee will also provide copies to the parents of the children in care for up to one year.

A copy of the LIC 9224 - Acknowledgement of Receipt of Licensing Reports was provided to the Director.

The deficiency listed on the following page was observed by the LPA and is being cited in accordance with California Code of Regulations Title 22 and/or the Health and Safety Code. Please see attached LIC 809d. Deficiency that is being cited needs to be cleared to protect the children’s health & safety.

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 Licensee. The Licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
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: PUENTE AVE PRESCHOOL INFANT CARE CENTER
FACILITY NUMBER: 198019478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2019
Section Cited

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Responsibility for Providing Care and Supervision
The licensee shall provide care and supervision as necessary to meet the children's needs.No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1).
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Supervision shall include visual observation.
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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) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2019
LIC809 (FAS) - (06/04)
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