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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191227188
Report Date: 10/29/2025
Date Signed: 10/29/2025 11:16:59 AM

Document Has Been Signed on 10/29/2025 11:16 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:MADISON PRESCHOOLFACILITY NUMBER:
191227188
ADMINISTRATOR/
DIRECTOR:		PATRICIA GUZMANFACILITY TYPE:
850
ADDRESS:750 N. LOS ROBLESTELEPHONE:
(626) 793-1181
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 22TOTAL ENROLLED CHILDREN: 13CENSUS: 5DATE:
10/29/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Special Education Teacher, Maria NinoTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On October 29, 2025 Licensing Program Analysts (LPA) Priscilla Ochoa conducted an unannounced Annual inspection. Upon arrival LPA met with Special Education Teacher, Maria Nino who guided LPA on a tour of the facility. This is a Preschool program which consists of 1 classroom. The facility is located on Madison Elementary School and is a part of the Pasadena Unified School DIstrict (PUSD). This is a half day program. Hours of operation for this facility are 7:45am-10:45am for AM, and 11:15am-2:15pm for PM. Per licensee, there are currently 13 enrolled in the program and LPA observed 5 children and 5 staff members.

At 10 am, LPA was guided on a tour of the facility. Parents enter through the main entrances of the Preschool and sign in their child. This Preschool program consists of 1 classroom: 5 children and 5 staff members. Teacher-child ratios were observed to be in accordance with Title 22 Regulations. Staff names were recorded. All children were observed to be under supervision, including visual supervision. No napping equipment was observed as this is a half day program. Per Special Education Teacher, students are able to have quiet time on a rug area where LPA observed a small coach and lounge chairs. There are age-appropriate toys and supplies for children in care and are in good repair in the classroom. Each child was observed to have their own cubbie to store personal belongings. The classroom was also observed to have their own restroom for children in care. LPA also observed a changing table in the restroom that met title 22 regulations. All toilets and hand washing facilities are in safe and sanitary operating condition. Drinking water is available in the form of personal water bottles that are also taken outside when needed. The facility provides additional water which is dispensed in the classroom for children in care. All areas were observed to be clean, orderly, comfortable, and well ventilated.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: MADISON PRESCHOOL
FACILITY NUMBER: 191227188
VISIT DATE: 10/29/2025
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The classroom furniture and equipment were inspected for good repair, free of sharp, loose, or pointed parts. All indoor classrooms were inspected to ensure that the floors have a surface that is safe and clean. All materials and surfaces accessible to children are toxic free.

The 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, swings, slides, and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard.

When a child becomes ill, they are isolated in the at a table near the entrance of the classroom, while parents are contacted.

The facility receives meals from Madison Elementary school. LPA reminded licensee that food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Storage areas are clean, free of litter, rubbish, and rodents/vermin. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are stored in an area inaccessible to children. The facility takes measures to keep the facility free of flies, other insects, and rodents. Per licensee, there are no weapons, firearms, or bodies of water on the premises.

LPA observed hardwired smoke detector and a functioning carbon monoxide detector in the classroom. LPA observed a fully charged 2A-10BC fire extinguisher. The valve on the fire extinguisher pointed to the fully charged green section. The fire extinguisher was serviced on 02/26/2025. Per Title 22, Emergency Disaster Drill must be conducted at least every 6 months. LPA observed Emergency Disaster Drill to be conducted and documented on 10/16/2025.

LPA reviewed Sign in and out sheets to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day.

Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. Child records were deemed complete.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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: MADISON PRESCHOOL
FACILITY NUMBER: 191227188
VISIT DATE: 10/29/2025
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LPA did not conduct staff file review as staff’s files are housed at the Pasadena Unified School District office located at 351 S. Hudson Ave. Pasadena, CA 91109. Files will be reviewed at a later date.

The Licensee is within the conditions, limitations, and capacity specified on the license. All areas were identified on the Facility Sketch were inspected. The following documents were posted: Facility License, Notification of Parents' Rights (PUB 393), Personal Rights (LIC 613A), PUB 269 Child Passenger System Poster, Daily Schedule and Meal Menu.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.

Incidental Medical Services (IMS) was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

The facility was constructed after 2010 and does is not required to test for lead: 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. LPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. This facility was

Licensee was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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: MADISON PRESCHOOL
FACILITY NUMBER: 191227188
VISIT DATE: 10/29/2025
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Licensee 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.

At this time, the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today, October 29, 2025.

A notice of site visit was given and must remain posted for 30 days during facility’s hours of operation. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, and a copy of the report was provided to Special Education Teacher, Maria Nino.



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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC809 (FAS) - (06/04)
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