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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191204631
Report Date: 07/15/2024
Date Signed: 07/15/2024 11:55:59 AM

Document Has Been Signed on 07/15/2024 11:55 AM - 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:SUSANNA WESLEY CHILDREN'S CENTERFACILITY NUMBER:
191204631
ADMINISTRATOR/
DIRECTOR:		RENEE SPIVEYFACILITY TYPE:
850
ADDRESS:134 N. KENWOOD ST.TELEPHONE:
(818) 548-6229
CITY:GLENDALESTATE: CAZIP CODE:
91206
CAPACITY: 36TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
07/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Renee Spivey, DirectorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Anomeh Eivazian, conducted an unannounced case- management inspection to the above facility on 07/15/24 at 11:15 am. LPA met with Renee Spivey, Director who guided LPA on a tour of the facility. During this inspection there were total of 8 preschoolers present in the facility with 2 staff.

Based on staff#1 and staff#2 interviews on 07/15/24 and child#1's record review, child#1 has allergy and has an Epi-Pen in the facility, which was expired on 04/2024. (Pictures were taken).



The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

LPA Eivazian informed director, Renee Spivey that this report dated 07/15/24 document(s) (1Type A citation). Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Eivazian informed the director, Renee Spivey to provide a copy of this licensing report dated 07/15/24 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Renee Spivey, director.

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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 2
Document Has Been Signed on 07/15/2024 11:55 AM - It Cannot Be Edited


Created By: Anomeh Eivazian On 07/15/2024 at 10:52 AM
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: SUSANNA WESLEY CHILDREN'S CENTER
FACILITY NUMBER: 191204631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2024
Section Cited
CCR
101226(e)(3)(A)

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101226(e)(3)(A)-- Health related Services (A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician.
This requirement is not met as evidenced by:
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Per Director, she will speak to child#1's parent today to bring in medication that is not expired, in addition, expired medication will be sent home. Upon children's return back to school the facility will ensure all of the conditions are met prior to accepting children back.
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Based on records review of Child #1's medication and staff disclosures the Epinephrine Injection was observed to have an expiration date of 04/2024.
This poses an immediate risk to children in care.
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Director will send pictures and documentation of new medication to LPA Eivazian via email on or before POC due date 07/16/24.

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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:Christina Gabelman
LICENSING EVALUATOR NAME:Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
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