191501069-8-25-2025-33-CC-SSAN-DKVQQN-20250825122236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191501069
Report Date: 08/25/2025
Date Signed: 08/25/2025 12:22:49 PM

Document Has Been Signed on 08/25/2025 12:22 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	SAN MARINO COMMUNITY CHURCH		FACILITY NUMBER:	191501069
ADMINISTRATOR/ DIRECTOR:	JIHAN MOUSSAUD		FACILITY TYPE:	850
ADDRESS:	1750 VIRGINIA RD		TELEPHONE:	(626) 282-4186
CITY:	SAN MARINO	STATE: CA	ZIP CODE:	91108
CAPACITY: 75	TOTAL ENROLLED CHILDREN: 75	CENSUS: 72	DATE:	08/25/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Jihan Moussaud		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/25/2025, at 09:00 am ,Licensing Program Analyst (LPA) Shushanik Safaryan conducted an unannounced annual random inspection to the above facility. At 09:15 am ,LPA met with Facility Representative Jihan Moussaud , who guided the LPA on a tour of the facility. This is a preschool age program which operates Monday through Friday from 8:00 am to 4:00 pm Program consists of 5 classrooms and nap room. Per Facility Representative facility operates on part time and extended care schedule .Part time program operates from 9:00 am-12:00 pm and extended care starts from 12:30 pm until 4:00 pm. Per Facility representative there are 79 children enrolled in both programs. LPA observed all required forms/publications posted by the front entrance visible to the parents . All the classrooms were inspected during the inspections . LPA toured the lion’s classroom (young 3) and observed 17 children with 2 staff members. Next LPA toured the Teddy Bear classroom (older 3) and observed 14 children with 2 staff members. LPA toured the Panda classroom (TK) and observed 16 children with 2 staff members . Next LPA toured Monkey classroom and observed 12 children with 2 staff members. LPA toured Elephant classroom(2 years old`s ) and observed 13 children with 2 staff members. Teacher child ratios were observed to be in accordance with Title 22 Regulations. Staff names were recorded. Licensed facility is within the conditions, limitations, and capacity specified on the license. All classrooms furniture and equipment were inspected for good repair, free of sharp, loose, or pointed parts. All 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. Page 1 of 5

NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Shushanik Safaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE:

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

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: SAN MARINO COMMUNITY CHURCH	FACILITY NUMBER: 191501069
	VISIT DATE: 08/25/2025

NARRATIVE

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Each classrooms have bathroom available to the children .All toilets and washing facilities are in safe and sanitary operating conditions. Monkey room and Elephant room have diaper changing area available to the children.

First Aid supplies are available and complete in each classroom and hallway.

LPA observed napping equipment and bedding in nap room . Napping equipment and bedding were inspected for good condition, appropriate storage, and cleanliness. Storage for children's belongings was inspected. Parents take linens home on Wednesday and Friday .

LPA observed that there are functioning smoke and carbon detectors in the facility. LPA observed a fully charged and serviced fire extinguisher with the service date 08/13/2025. Emergency disaster drill was last conducted on 07/18/2025. Facility representative states there are no weapons, firearms, or bodies of water on the premises.

Snacks and lunches are provided by the parents. LPA observed emergency snacks stored in the office area and staff lounge area. Snacks were reviewed for availability, quantity, and appropriateness to children in care.

All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids. Drinking water is readily available both indoors and outdoors via water bottles provided by the parents and refill provided by the facility via Arrowhead company that gets delivered every 2 weeks . The facility was observed to be free of flies, other insects, and rodents.

The office area and staff restroom are used for the ill children. Cot will be available upon request. LPA toured the outdoor play area . 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, slides, and similar equipment are cushioned with material that absorbs a fall. LPA observed sand as a material that absorbs fall . Per facility representative , sand replaced every year. Custodian from church racks sand every morning before use. There is adequate shade in the play yard. Page 2 of 5

NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Shushanik Safaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

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: SAN MARINO COMMUNITY CHURCH	FACILITY NUMBER: 191501069
	VISIT DATE: 08/25/2025

NARRATIVE

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Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. Facility uses a program called Bright Wheel to sign children in and out.

Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. Inspection of required forms was made and documented on the LIC 857.

LPA reviewed staff records; staff files were complete. Criminal Records Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed.

There is at least one person trained in CPR and Pediatric First Aid present during this inspection. The review of Staff records was documented on the LIC 859.

Staff present had proof of the AB 1207 Mandated Reporter Training certificate on file. AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018, any person who works in a childcare facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.

SB792 (Immunization Requirements for Staff and Employees) was discussed with the Director.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and

administrative records.
For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.
LPA advised the licensee to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Shushanik Safaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

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: SAN MARINO COMMUNITY CHURCH	FACILITY NUMBER: 191501069
	VISIT DATE: 08/25/2025

NARRATIVE

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LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Facility Representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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 childcare 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 with the Written Directives outlined in PIN 21-21.1-CCP.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Shushanik Safaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

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: SAN MARINO COMMUNITY CHURCH	FACILITY NUMBER: 191501069
	VISIT DATE: 08/25/2025

NARRATIVE

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Based on the LPA`s observations and record review the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative.

An exit Interview was conducted, a copy of this report along with Notice of Site visit provided to the Facility Representative , Jihan Moussaud on 08/25/2025.

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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Shushanik Safaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

LIC809 (FAS) - (06/04)

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