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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191203005
Report Date: 03/30/2022
Date Signed: 03/30/2022 11:49:22 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2022 and conducted by Evaluator Nolan Tcheng
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20220215160903
FACILITY NAME:OUR SCHOOLFACILITY NUMBER:
191203005
ADMINISTRATOR:JANEL THRASHERFACILITY TYPE:
850
ADDRESS:1800 EAST MOUNTAIN ST.TELEPHONE:
(626) 798-0911
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:48CENSUS: 36DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Janel Thrasher - Director TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Licensee denied child's authorized representative(s) entrance into the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced inspection for the purpose of delivering complaint findings. Upon arrival at 11:30am, LPA met with Director Janel Thrasher, to whom the purpose of the visit was explained. At 11:35am, LPA was given a tour of the facility where there were children present at the time of inspection.

Census was taken. There were 8 children and 1 staff in Room 1, 6 children and 1 staff in Room 2, 10 children and 1 staff in Room 3, and 12 children and 1 staff in Room 4.

During the course of the investigation, Interviews were conducted with six staff, six children, and five parents. LPA obtained documentation in the form of Child Care Roster, COVID-19 Protocols, Admission Contract, and Tuition Contract.

REPORT CONTINUES PAGE 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 33-CC-20220215160903
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: OUR SCHOOL
FACILITY NUMBER: 191203005
VISIT DATE: 03/30/2022
NARRATIVE
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Information from the complainant indicates that licensee does not allow children’s authorized representatives entrance into the facility.

During interview, Director states that parents have not been allowed to enter facility. New parents are allowed to observe only outside and are allowed to bring the prospective child during this time. When a parent requests to enter the facility they have only been brought to the back patio for conferences or meetings. Director states that there is “No visiting” when asked about the facility visitor policy. Parents also have pick up and drop off times for the children each day. Director provided licensing staff with Letter to parents sent in August 2021 that notes Parents will remain in their vehicles the facility “Welcome Table” when dropping off their children and that only children should come to table. The last note on the letter states that the facility is still a “closed campus.”

Interviews with staff corroborate that parents are not entering the facility. Staff #2 and #5 interviews supported the allegation that parents are not allowed to enter facility. Staff #2 disclosed that they only see parents of the children in the driveway because of COVID, and later noted that though there are tours, parents do not come in. Staff #5 states that the facility is a “closed campus” and that families are not allowed to do “ins and outs.” Staff interviews also disclosed that tours for prospective parents use to only take place after hours but have recently only allowed adults in for tours, as long as they follow the health and safety protocols, and that they do not enter the classrooms.

Parent interviews disclosed that parents have not been coming in the facility. Parents were asked if they requested, would they be allowed in the facility. Parent #2 states that part of the facility protocol is that “no one is allowed in but staff and children.” Parent #3 stated during interview that they are not allowed to come in during COVID.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 Chapter 1 101218.1), are being cited on the attached deficiencies page.

Please refer to attached 9099D for documentation of deficiencies.

Exit interview was conducted with Director Janel Thrasher, at 12:15pm . A copy of the report was provided.

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. END OF REPORT PAGE 2 of 2

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 33-CC-20220215160903
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: OUR SCHOOL
FACILITY NUMBER: 191203005
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2022
Section Cited
CCR
101218.1(b)(1)
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Admission Procedures and Parental and Authorized Representative's Rights
At the time of acceptance of each child in care, the licensee shall inform each child's parent or authorized representative of his/her rights...(1)To enter and inspect the child care center.
This requirement was not met as evidenced by:
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Per Director, they will put out an email to let parents know they can come into the facility if they would like to. Director will send me a copy of the email that goes out to parents, by POC date.
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Based on interview and record review, Licensee did not ensure that parents were allowed to enter the facility during the COVID Pandemic. Parents are to be allowed entrance into the facility as it is their right as an authorized representative. This posed a potential risk to the health, safety and personal rights of children in care.
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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.
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5