198400381-6-15-2021-54-CC-AJLO-C3ZQ49-20210615114957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400381
Report Date: 06/15/2021
Date Signed: 06/15/2021 11:50:21 AM

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:	GROW AND LEARN CENTER		FACILITY NUMBER:	198400381
ADMINISTRATOR:	PETER, DEBRA		FACILITY TYPE:	850
ADDRESS:	12183 FIRESTONE BLVD.		TELEPHONE:	(562) 556-1338
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	30	CENSUS: 0	DATE:	06/15/2021
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Debra Peter & Betty Hannah, Applicants		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An in-person office meeting was held on this date with Licensing Program Analyst (LPA) A. Lucero and applicants Debra Peter and Betty Hannah. The purpose of the office meeting was to review the Application for Child Care Centers with the applicants and to further discuss what needs to be submitted for the pending application packet as stated in the LIC 184-b dated 06/10/2021. · Application (LIC 200A) – currently states this is a “change of ownership.” · Orientation Training Certificate – submit proof of Step I & Step II certificates for Debra Peter · Administration Organization (LIC 309) – indicate which type of partnership for each (ex: general/limited) and indicate obligations/duties of each general partner · Personnel Policies: o Employee rights o Child abuse reporting procedure o Hiring practices and conditions of employment o Inspection Authority of Licensing Department · Job Descriptions: o Include minimum qualifications o Lines of supervision – whom reports to whom? · In-service Training for Staff: o Indicate what staff will receive training o Indicate who will give the training o Indicate the topics to be covered · LIC 9108 – submit for Debra Peter & Betty Hannah · Mandated Reporter Training Certificate (AB 1207) – submit for Debra Peter & Betty Hannah · Facility Sketch (LIC 999)

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: GROW AND LEARN CENTER	FACILITY NUMBER: 198400381
	VISIT DATE: 06/15/2021

NARRATIVE

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o Indoor Sketch – indicate the dimensions and on/off limit areas
o Isolation area
o Staff bathroom
o Outdoor Sketch – indicate on/off limit areas
· LIC 610 – Needs to be completely filled out. Needs relocation sites with permission letters
· Evidence of Control of Property – Submit Rental/Lease Agreement
· Program description:
o Category and age of children (please indicate ages, not grades)
o Supplementary or optional services
o Field trip provisions
o Transportation arrangements
o Food service provisions
o Medication policy/plan
o Services provided during a medical and dental emergency
· Admission Policies:
o Notification of Parents Rights LIC 995
o Personal Rights LIC 613A
o Identification and Emergency Contact LIC 700
o Consent for Emergency Medical Treatment LIC 627
o Childs Preadmission Health History LIC 702
o Physicians Report LIC 701
o Immunization Requirements
· Admission Agreement:
o Include modification conditions (30 day notice for rate change)
o Refund policy
o Reasons for termination
o Rights of licensing agency
o Place for signature for all parties involved
· Rules of Discipline – include grounds for dismissal
· Sample Menus:
o Portion size

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: GROW AND LEARN CENTER	FACILITY NUMBER: 198400381
	VISIT DATE: 06/15/2021

NARRATIVE

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·Criminal Record Statement (LIC 508) – submit for Debra Peter & Betty Hannah
· Fingerprint Transfer Request - Submit LIC 9182 for Debra Peter & Betty Hannah
· Applicant Information (LIC 215) – submit for Debra Peter
· Personnel Record (LIC 501) – submit for Debra Peter
· First Aid/CPR cards – Submit for Debra Peter
· Preventative Health Practices, One Hour Nutrition, One-hour Lead Training – submit for Betty Hannah
· Health Screening Report (LIC 503) – Submit current one (within one year) for Debra Peter
· Immunization Records (Influenza, MMR, Tdap) – submit for Debra Peter
· Influenza – submit proof or declination letter for Betty Hannah
* Copy of Liability Insurance as stated in Lease Agreement

The applicants are to submit all requested documents by Close of Business (COB) on Friday, June 25, 2021. If the documents are not submitted by the due date given, the Monterey Park South West Office will begin the Denial Process of the application. LPA also provided a copy of the LIC 184-b dated 06/10/2021 and Notification of Incomplete Application Letter dated 06/10/2021. An exit interview was conducted, and a copy of this report was provided to the applicants.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC809 (FAS) - (06/04)

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