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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019478
Report Date: 10/14/2022
Date Signed: 10/14/2022 05:34:25 PM


Document Has Been Signed on 10/14/2022 05:34 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 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:45CENSUS: 26DATE:
10/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Kimberly NguyenTIME COMPLETED:
05:40 PM
NARRATIVE
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On October 14, 2022 at 4:10 pm, Licensing Program Analyst (LPA) Carolyn Tuba conducted an unannounced case management deficiency. LPA met with Director, Kimberly Nguyen. A census was taken and there was 26 children and 8 staff in care.

The purpose of this inspection is to cite due to non-reporting requirements in the first 24 hours of the incident. During this visit LPA consulted with the Director of the regulation requirements that a phone call should be conducted the first 24 hours and an Unusual Incident Report needs to be issued 7 days from the incident. On September 16, 2022 an incident was self reported to the assigned LPA, Tuba by the Director via telephone. The incident occurred on September 9, 2022 and LPA asked Director if the incident had been reported the first 24 hours and Director stated that this was the first time they were calling. LPA advised of regulation requirements of reporting.

The following deficiencies on the attached LIC 809 deficiencies page is being cited in accordance with CA code of Regulations Title 22. 101212(d)(1) Reporting Requirements.



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, appeal rights, a copy of this report and the notice of site visit was given to Director, Kimberly Nguyen.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Carolyn TubaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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Document Has Been Signed on 10/14/2022 05:34 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 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: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited

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Reporting Requirements
(d) 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
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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 information specified in (d)
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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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Carolyn TubaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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