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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191597150
Report Date: 07/28/2026
Date Signed: 07/28/2026 03:58:48 PM

Document Has Been Signed on 07/28/2026 03:58 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:OPTIONS-SURROUND CARE-JELLICKFACILITY NUMBER:
191597150
ADMINISTRATOR/
DIRECTOR:		MILDRED BALDERRAMAFACILITY TYPE:
840
ADDRESS:1400 S. JELLICK AVETELEPHONE:
(626) 912-1776
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: 42DATE:
07/28/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Rachel SIlva - Lead TeacherTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced Case Management inspection for the purpose of following up on an incident reported to the Department on 06/30/2026. Upon arrival at 1:35pm, LPA met with Facility Representative Rachel Silva, to whom the purpose of the inspection was explained. A tour of the facility was provided and census was taken. There were 42 children with 7 staff members.

On 06/30/2026, the facility took a field trip off site. At around 2pm, Child #1's parent came to pick up their child from the facility, only to be told the child was not there by facility staff. Child #1 was confirmed to be on the trip with the rest of the children. During today's inspection, LPA conducted interviews with three staff members and one adult. Documentation in the form of attendance sheets for 06/30/2026, field trip sign up for attendance sheet for 06/30/2026, and Parent handbook reviewed. Pictures were also obtained during today's inspection of postings for the next field trip being conducted.

Per Parent #1, they did not sign up Child #1 (C1) for the field trip and gave no consent regarding the trip. They normally drop their child off during the summer 1-2 times a week and they were not notified of any field trip occurring that day (06/30/2026). Staff #1 states that permission trips are signed for each separate field trip. Children were staying on site that day with available staff due to summer school at the elementary school campus as well as late drop offs. Per Staff #2, "Somehow [C1] got an orange shirt, so the teacher that was there and assumed [C1] was verified for the trip. We think [C1] may have just grabbed one and wasn't marked off. When we looked back on it, [C1] wasn't signed to be on the trip." Staff #2 explained that field trip shirts are given the day of the trip to children. Per Staff #3, there were 84 children on the trip that day, with 4 children staying behind. For a total of 88 children.

REPORT CONTINUES PAGE 1 of 2

Ana Chico
Nolan Tcheng
DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: OPTIONS-SURROUND CARE-JELLICK
FACILITY NUMBER: 191597150
VISIT DATE: 07/28/2026
NARRATIVE
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LPA reviewed the sign in documentation and the field trip sign up list. LPA observed that Child #1 was not on the list, nor Parent #1's name. LPA reviewed the sign in/meal count list and observed C#1's name present there. Staff #1-3 all confirmed that Child #1 was on the trip and that they were not signed up for the field trip that day. This was a violation of Admission Policies, as a child was who was not signed up for on a field trip, was taken on a field trip against parent's consent.

The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D for deficiencies that are being cited and need to be cleared to protect the children’s health & safety.

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

Exit interview conducted and report was reviewed with Facility Representative Brenda Monroy, at 3:55pm. Plan of corrections was developed and Copy of Report provided.

END OF REPORT

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Nolan Tcheng
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/28/2026 03:58 PM - It Cannot Be Edited


Created By: Nolan Tcheng On 07/28/2026 at 03:39 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: OPTIONS-SURROUND CARE-JELLICK
FACILITY NUMBER: 191597150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2026
Section Cited
CCR
101218(a)(5)

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(a) Every child care center shall have all admission policies in writing and available to the public. The policies shall coincide with the limitations stated on the license, and shall include, but not be limited to, the following:
(5) Field-trip provisions, if any.
This requirement is not met as evidenced by:
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Per Facility Representative, specific staff will handle signatures for sign up, and a specific staff for shirts and head count. Before it was word of mouth and postings on fence, now it will be Hubbe notification, word of mouth, and postings on fence. Stations will be utilized for lunches, shirts
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Based on record review and interview, licensee did not ensure field trip provisions were met when Child #1 was taken on the field trip without permission/consent from authorized representative. This was a potential risk to the health, safety, and personal rights of children in care
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and headcount for field trips. Children will be grouped off beforehand once they are signed up, so the day of, if there is a child that is not on the list it will raise an alert to double check. This will be drafted as a training/memo and sent to LPA by POC date.

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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.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Nolan Tcheng
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2026


LIC809 (FAS) - (06/04)
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