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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191223032
Report Date: 09/12/2024
Date Signed: 09/12/2024 11:51:03 AM

Document Has Been Signed on 09/12/2024 11:51 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:LA CRESCENTA PRESBYTERIAN CTR. FOR CHILDRENFACILITY NUMBER:
191223032
ADMINISTRATOR/
DIRECTOR:		CHAMBERS, PATRICIAFACILITY TYPE:
840
ADDRESS:2902 MONTROSE AVENUETELEPHONE:
(818) 249-8124
CITY:LA CRESCENTASTATE: CAZIP CODE:
91214
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 0DATE:
09/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Julie Larson TIME VISIT/
INSPECTION COMPLETED:
09:30 AM
NARRATIVE
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On 09/12/24 , at 08:30 am , Licensing Program Analyst (LPA) Shushanik Safaryan conducted Case Management visit to amend report (LIC 9099) and citation(LIC 9099D) issued on 08/01/24.

During this visit LPA met with the Facility Representative , Patricia Chambers , to whom the reason of the visit was explained . Tour was provided . During the visit , no children were present .

LIC 809D attached to this report referred to the LIC 9099 dated 08/01/24.

Exit interview was conducted with Facility Representative Patricia Chambers and amended documents were provided. Appeal rights explained ,Notice of Site visit provided and must remain posted for 30 days .

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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Document Has Been Signed on 09/12/2024 11:51 AM - It Cannot Be Edited


Created By: Shushanik Safaryan On 09/12/2024 at 06:58 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
FACILITY NUMBER: 191223032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2024
Section Cited
CCR
101212(d)(1)(C)

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101212 Reporting Requirements d)Upon...occurrence... any... events specified..below, report shall be made ... by telephone...fax within the.. next working day and during... business hours...(1)Events reported...(C)Any unusual incident. This requirement is not met evidenced by :
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LIcensee will complete unussual incident report and will send it to the Department. Licensee will review Reporting Requirements with office staff and Declaration will be submited to LPA by POC date .
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Last summer child was left unattended inside of the van .This event was not reported to the Department.

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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:Brandi VanOosten
LICENSING EVALUATOR NAME:Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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