191203005-10-2-2024-33-CC-NTCG-D9NS6L-20241002133607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191203005
Report Date: 10/02/2024
Date Signed: 10/02/2024 01:36:15 PM

Document Has Been Signed on 10/02/2024 01:36 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	OUR SCHOOL		FACILITY NUMBER:	191203005
ADMINISTRATOR/ DIRECTOR:	JANEL THRASHER		FACILITY TYPE:	850
ADDRESS:	1800 EAST MOUNTAIN ST.		TELEPHONE:	(626) 798-0911
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 66	TOTAL ENROLLED CHILDREN: 66	CENSUS: 48	DATE:	10/02/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:55 AM
MET WITH:	Tiffany Thrasher - Lead Teacher		TIME VISIT/ INSPECTION COMPLETED:	01:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced annual inspection. Upon arrival at 10:55am, LPA met with Lead Teacher Tiffany Thrasher. At 11:05am, LPA was led on a tour of the facility. This is a Preschool program which consists of 5 classrooms. Per licensee, there are currently 52 enrolled in the program. Hours of operation for this facility are 8am-5pm, Monday-Friday.

Licensing staff observed all required forms/publications to be posted in the office. Menus for the past 30 days are available upon request.

At 11:05am, LPA entered and inspected Class 1 (2s): 5 children with 1 staff member, Class 2 (Young 3s): 9 children with 2 staff members, Class 3 (Older 3s): 9 children with 2 staff members, Class 4 (Pre-K): 12 children with 2 staff members, and Class 5 (Adv. Pre-K): 13 children with 2 staff members. 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.

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. Drinking water was readily available indoors. At this time, the office is used as an isolation area. A cot 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. Lead Teacher states there are no weapons and firearms on the premises.

At 11:15am, LPA reviewed the storage of napping equipment. Cots are stored on a rack in the back patio area. Napping equipment was observed to be cots. Napping linens are stored individually.

REPORT CONTINUES PAGE 1 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: OUR SCHOOL	FACILITY NUMBER: 191203005
	VISIT DATE: 10/02/2024

NARRATIVE

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At 11:20am, a fire extinguisher was observed. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 07/14/2024, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. Smoke and carbon monoxide detectors were tested and are operable.

There are two restroom areas. One located in between Class 1 and 2, and another restroom located by Class 5. All toilets, hand washing, and bathing facilities are safe, sanitary and are operating properly.

There is no kitchen at this facility. Lunch is provided from each child's family for their own child. This facility provides AM and PM snack. Food was reviewed for availability, quantity, and appropriateness. Snack menus are provided in the welcome packet for each school year.

At 11:25am, 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, slides, and similar equipment are cushioned with material that absorbs a fall. The outdoor play area is located on the east side of the property. There are shaded benches with toys/activities for children to play. There is also a play area by Class 4 that has small slide and small play structure for children to use. Drinking water is readily available outdoors.

LPA observed swimming pool in the middle of the property that is incorporated in the facility curriculum during the appropriate seasons. The pool has a 5ft gate surrounding the body of water. There is a self latching gate that opens away from the pool. The gate's latch is no more than 6 inches from the top of the gate and has a padlock on it. It is constructed as to not obscure the pool from view and is strong enough to withstand force against it. Each vertical railing of the gate is no more than 4in apart and the bottom of the gate is no more than 4in from the ground. There is a lifeguard present during swim time as well as staff positioned outside and inside the pool to help supervise all children.

Teacher-child ratios were observed to be in accordance with Title 22 regulations. Staff names were recorded. All children were observed to be under visual supervision of a teacher during tour. The Licensee is within the conditions, limitations, and capacity specified on the license. All areas were identified on the Facility Sketch were inspected.

REPORT CONTINUES PAGE 2 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 10/02/2024 01:36 PM - It Cannot Be Edited

Created By: Nolan Tcheng On 10/02/2024 at 01:13 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: OUR SCHOOL	FACILITY NUMBER: 191203005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/02/2024

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 4 of 6 staff files, Staff #1-3 & 6, did not have proof of Mandated Reporter Child Care Provider (AB1207) completion, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Per Lead Teacher, they will have Staff #1-3 & 6 complete the Mandated Reporter Child Care Provider (AB1207) training and submit proof to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Chico

LICENSING EVALUATOR NAME:

Nolan Tcheng

LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: OUR SCHOOL	FACILITY NUMBER: 191203005
	VISIT DATE: 10/02/2024

NARRATIVE

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At 12:10 pm, facility records were reviewed. 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. Disaster drills have been conducted at least every six months. Staff files were reviewed for a health screening report and immunizations that meet regulatory requirements. 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. During review of staff files, LPA observed that 4 of 6 Staff files did not have a current Mandated Reporter Child Care Provider (AB1207) proof of completion. LPA discussed with Lead Teacher the requirement to have it completed every two years. A random sample of Children’s Records were reviewed to ensure that they are complete.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Facility Representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP

REPORT CONTINUES PAGE 3 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: OUR SCHOOL	FACILITY NUMBER: 191203005
	VISIT DATE: 10/02/2024

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Lead Teacher Tiffany Thrasher, at 1:25pm. Plan of corrections were developed and Copy of Report provided.

END OF REPORT PAGE 4 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

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