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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019873
Report Date: 11/16/2021
Date Signed: 11/16/2021 01:32:12 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:ENCHANTED CASTLE SAN MARINO MONTESSORI SCHOOLFACILITY NUMBER:
198019873
ADMINISTRATOR:JESSICA CHANGFACILITY TYPE:
850
ADDRESS:444 & 464 S. SIERRA MADRETELEPHONE:
(626) 577-8007
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:104CENSUS: 79DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Parima Madan - DirectorTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced random annual/required inspection. Upon arrival at 8:55am, LPA met with Director Parima Madan. At 9:05am, director led LPA on a tour of the facility. This is a preschool program which consists of 5 classrooms. Per licensee, there are currently 97 enrolled in the program. Hours of operation for this facility are 7am-6pm, Monday-Friday.

Licensing staff observed all required forms/publications to be posted in the classrooms. Snack menus were reviewed to ensure that they are being 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.

PHYSICAL PLANT: At 9:15am, LPA entered and inspected the classrooms. LPA observed Room 1: 14 children with 2 staff members, Room 2: 17 children with 2 staff, Room 3: 18 children with 4 staff, Room 4: 16 children with 3 staff, and Room 5: 14 children with 2 staff. Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts. All floors are clean and safe. A fire extinguisher was observed. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 07/22/2021, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. Drinking water was readily available in each classroom. LPA reviewed the storage of napping equipment in each classroom. Napping equipment was observed to be cots. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids. The facility was observed to be free of flies, other insects and rodents. Sufficient individual storage space for children was observed and each child has a cubby. At this time, the office is used as an isolation area. A mat is available for an ill child to rest on. First Aid supplies are available and complete. Facility has a functioning carbon monoxide detector that meets statutory requirements. Smoke and carbon monoxide detectors were tested and are operable. Director states there are no weapons, firearms, or bodies of water on the premises. REPORT CONTINUES PAGE 1 of 3

SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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: ENCHANTED CASTLE SAN MARINO MONTESSORI SCHOOL
FACILITY NUMBER: 198019873
VISIT DATE: 11/16/2021
NARRATIVE
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All toilets, hand washing, and bathing facilities are safe, sanitary and are operating properly. All food preparation areas and food storage areas are kept clean and are free of litter, rubbish and rodents and/or any other vermin. Snacks were reviewed for availability, quantity and appropriateness to children in care. This facility provides am snack and pm snack.

OUTDOORS: At 9:25am, LPA reviewed the outdoor play area. Outdoor playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with material that absorbs a fall. There is one outside play space that is located next to Room 5. Another outside play space observed play structure area next to Room 4. A large play area was observed in the back corner of the yard. Drinking water is readily available outdoors.

FACILITY RECORDS: Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. Staff files were reviewed for a health screening report and immunizations that meet regulatory requirements. LPA observed during file review, that Staff #11 was missing their LIC503 Health Screening Report,. Criminal Record Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed. The name of the child care center director or fully qualified teacher(s) designated to act in the director's absence is on file. Educational background, training, and/or experience for each staff present are on file and were reviewed. Mandated Reporter - Child Care Provider (AB1207) Training was reviewed in each file. LPA observed Staff #1, #7, #10, and #13 did not have a current Mandated Reporter Training certificate. A random sample of Children’s Records were reviewed to ensure that they are complete.

INCIDENTAL MEDICAL SERVICES:


This facility provides Incidental Medical Services –( IMS). Facility has submitted IMS plan for all locations. 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

REPORT CONTINUES PAGE 2 of 3

SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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: ENCHANTED CASTLE SAN MARINO MONTESSORI SCHOOL
FACILITY NUMBER: 198019873
VISIT DATE: 11/16/2021
NARRATIVE
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LPA advised the licensee how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov. AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com/

The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D for deficiencies that are being cited and need 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.


Exit interview was conducted with Director Parima Madan at 1:20pm, and Plan of Corrections were reviewed and developed. A copy of the report was provided.

SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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: ENCHANTED CASTLE SAN MARINO MONTESSORI SCHOOL
FACILITY NUMBER: 198019873
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 interview and record review, the licensee did not comply with the section cited above in four out of fourteen staff files were missing current Mandated Reporter - Child Care Provider certificates, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2021
Plan of Correction
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Per director, they have Staff #1, #7, #10, and #13 complete the Mandated Reporter - Child Care Provider Training and submit the proof of completion to LPA by POC date.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

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 one out of fourteen staff files was missing a completed and signed LIC503 Health Screening Report, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2021
Plan of Correction
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Per director, they will have Staff #11 complete a health screening with their physician and submit a copy of the health screening report to LPA by 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: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4