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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222458
Report Date: 09/09/2022
Date Signed: 09/09/2022 03:55:09 PM

Document Has Been Signed on 09/09/2022 03:55 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:LA CRESCENTA PRESBYTERIAN CTR. FOR CHILDREN/INFANTFACILITY NUMBER:
191222458
ADMINISTRATOR:PATRICIA CHAMBERSFACILITY TYPE:
830
ADDRESS:2902 MONTROSE AVE.TELEPHONE:
(818) 249-8124
CITY:LA CRESCENTASTATE: CAZIP CODE:
91214
CAPACITY: 20TOTAL ENROLLED CHILDREN: 15CENSUS: 10DATE:
09/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Patricia Chambers, DirectorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced case management inspection on 09/09/2022, due to an incident that occurred on Monday May 2, 2022 and Thursday May 5, 2022. LPA arrived at the facility at 10:20 a.m. and met with Particia Chambers, Director who guided analyst on a tour of the facility.

Alleged Incidents took place on 05/02/2022 and 05/05/22. Incident was reported via FAX on 05/27/22. Original LIC 624 Unusual Incident/Injury Report form was received by the Department on 05/27/22 at 3:22 p.m. via FAX. The facility did not report the incident within the required 24 hour time frame.

LPA observed the area where alleged incidents took place on 05/02/22 and 05/05/22. Classroom floor is covered with carpet. During this inspection LPA conducted interviews with staff#2, staff#3 and staff#4.

Per staff#3, on 05/02/22 staff#3 was in classroom with staff#1. Per staff#3, staff#3 was in mat area and tapping on two infants to fall asleep, at the same time staff#1 was on the chair with child#1. Per staff #3, child#1 drank milk and staff #1 was tapping on child#1's back to help child#1 burp. At that time staff#3 heard child#1 was crying, turned around and noticed child#1 slipped off the staff#1's lap and reached the floor. Per staff#3, child#1 was checked by staff#1 and staff #3 and did not observe any marks or injury on child#1. This incident was not reported to child#1's parent until facility director was informed on 05/26/22 that on 05/02/22 while staff#1 fell asleep, child#1 slipped off the staff#1's lap while sitting.

Per staff#4, on 05/05/22 while staff#4 was inside the classroom with staff#1 and folding laundry, in a way seeing staff#1. Staff#4 observed staff#1 was feeding child#1 while sitting on a chair, turned the child#1 face down to the ground and tapped on child#1's back for burp, at that time staff#1 had fallen asleep and child#1 was dropped down on the floor on face. Per staff#4, this incident was reported to the facility next day.
REPORT CONTINUES ON NEXT PAGE 1 of 2
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LA CRESCENTA PRESBYTERIAN CTR. FOR CHILDREN/INFANT
FACILITY NUMBER: 191222458
VISIT DATE: 09/09/2022
NARRATIVE
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Per staff#2, on 05/05/22 staff#1 dropped child#1 from a sitting position while had fallen asleep. Staff#4 was present in the classroom. Per staff#2, staff#1 does not work at this school anymore.

Ratio and staffing were in accordance of Title 22 Code of Regulations at the time of the both incidents on 05/02/022 and 05/05/22. There were 5 infants with two staff on 05/02/22 and 05/05/22 at the time of incident.

LPA issued the Confidential Names List (LIC 811) to the licensee during this inspection. The Confidential Names List documents the staff and children involved with the incidents documented in this report.


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.

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 director, Patricia Chambers at 12:30 p.m..


REPORT END 2 of 2
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 09/09/2022 03:55 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 09/09/2022 at 11:45 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: LA CRESCENTA PRESBYTERIAN CTR. FOR CHILDREN/INFANT
FACILITY NUMBER: 191222458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
101223(b)

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101223 (b)-- Personal Rights
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met as evidenced by...
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Per director, staff#1 does not work at this school anymore. All current staff had training about care and supervision and reporting requirement.
A written plan will be submitted to LPA by plan of correction due date 09/30/22.
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Based on interviews that were conducted with staff#2, staff#3, and staff#4 on 09/09/22, staff#1 fell asleep on 05/02/22 and 05/05/22 while had child#1 in hand and child#1 fell down on the floor while staff#1 was sitting on the chair.
This is a potential health, safety, personal right risk to children in care.
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Type B
09/30/2022
Section Cited
CCR101212(d)

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Reporting Requirements-- Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department etc...
This requirement was not met as evidenced by...
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Per director, she conducted a training to all current staff about reporting requirement to ensure to keep the office informed about any incident. Per director, all reportable incidents will be reported to Regional Office in a timely manner.
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Based on interviews conducted on 09/09/22 with staff#2 and staff#4, on 05/02/22 and 05/05/22 staff#1 had fallen asleep while had child#1 in hand and child#1 fell down on the floor and not reported to CCL till 05/27/22.
This poses a potential health, safety and personal right to children in care.
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A written plan will be submitted to LPA by plan of correction due date 09/30/22.
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: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/09/2022 03:55 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 09/09/2022 at 12:20 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: LA CRESCENTA PRESBYTERIAN CTR. FOR CHILDREN/INFANT
FACILITY NUMBER: 191222458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
101212(f)

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101212 (f)--Reporting Requirements The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.
This requirement was not met as evidenced by...
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Per director, she conducted a training to all current staff about reporting requirements. Per director, all reportable incidents will be reported to Regional Office and parents in a timely manner. A written plan will be submitted to LPA by plan of correction due date 09/30/22.
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Based on interviews conducted on 09/09/22 with staff#2, #3, and #4, on 05/02/22 and 05/05/22, staff#1 had fallen asleep while had child#1 in hand and child#1 fell down on the floor and the incident was not reported to child#1 parents same day.
This poses a potential health, safety and personal right to 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.
SUPERVISOR'S NAME:Christina Gabelman
LICENSING EVALUATOR NAME:Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


LIC809 (FAS) - (06/04)
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