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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191224296
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:49:27 PM

Document Has Been Signed on 08/30/2023 03:49 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:PARK MONTESSORI CHILDREN'S CTR.FACILITY NUMBER:
191224296
ADMINISTRATOR:PARK, GRACEFACILITY TYPE:
850
ADDRESS:13130 HERRICK AVE.TELEPHONE:
(818) 367-5483
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 75TOTAL ENROLLED CHILDREN: 75CENSUS: 29DATE:
08/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Hannah Park, DirectorTIME COMPLETED:
04:05 PM
NARRATIVE
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On Wednesday, August 30, 2023 Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced case management inspection and met with Director Hannah Park. During this visit, LPA Rivera reviewed staff files and observed the staff files to be incomplete. LPA informed Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year, staff missing LIC 503 Health Screening Report, and staff missing AB 1207 Child Abuse Mandated Reporter Certificate.

During the visit LPA Rivera explained the citations and director provided the plan of correction. Due date September 29, 2023.

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

An exit interview was conducted, during which this report and the Appeal Rights were discussed with Director Hannah Park.


SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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 08/30/2023 03:49 PM - It Cannot Be Edited


Created By: Mayra Rivera On 08/30/2023 at 03:12 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: PARK MONTESSORI CHILDREN'S CTR.
FACILITY NUMBER: 191224296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
HSC
1596.7995

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Employees or volunteers at day care center; immunization requirements; records; exemptions. (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against
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Director Hannah stated, she will informed staff to provide and complete the immunizations requirement and have it completed within the 30 days.
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influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. Based on record review, the licensee did not comply with the section cited above in not having staff provide immunization record which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/29/2023
Section Cited
CCR101216

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Personnel Requirements-(g) All personnel, including the licensee, administrator and volunteers, shall be in good health and shall be physically and mentally capable of performing assigned tasks. (1) Except as specified in (3) below, good physical health shall be....
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Director Hannah stated, she will informed staff to provide or complete the LIC 503 Health Screening Report within the 30 days.
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Based on record review, the licensee did not comply with the section cited above in not having staff complete LIC 503 Health Screening Report record which poses a potential health, safety or personal rights risk to persons 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:Lady King
LICENSING EVALUATOR NAME:Mayra Rivera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/30/2023 03:49 PM - It Cannot Be Edited


Created By: Mayra Rivera On 08/30/2023 at 03:26 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: PARK MONTESSORI CHILDREN'S CTR.
FACILITY NUMBER: 191224296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2023
Section Cited
HSC
1596.8662

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Availability of information regarding detecting and reporting child abuse and neglect; training for mandated reporter who is licensed day care provider, administrator, or employee of a licensed child day care facility; proof of completion 2) Provide training including statewide guidance on the responsibilities of a
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Director Hannah stated, she will informed staff to provide or complete the AB 1207 Child Abuse Mandated Training within the 30 days.
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2) Provide training including statewide guidance on the responsibilities of a mandated reporter... Based on record review, the licensee did not comply with the section cited above in not having staff complete the AB 1207 Child Abuse Mandated Training which poses a potential health, safety or personal rights risk to persons 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:Lady King
LICENSING EVALUATOR NAME:Mayra Rivera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


LIC809 (FAS) - (06/04)
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