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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191597486
Report Date: 04/08/2026
Date Signed: 04/08/2026 01:54:17 PM

Document Has Been Signed on 04/08/2026 01:54 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:MADISON/CHILD DEVELOPMENT CENTERFACILITY NUMBER:
191597486
ADMINISTRATOR/
DIRECTOR:		KYM ALLENFACILITY TYPE:
850
ADDRESS:1351 S. MAIN STREETTELEPHONE:
(909) 622-9805
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 96TOTAL ENROLLED CHILDREN: 96CENSUS: 13DATE:
04/08/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Sofia AquinoTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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This incident took place at Madison Elementary School facility number 191597486.

Licensing Program Analyst (LPA) Kamile Martin conducted an unannounced Case Management Inspection due to an incident that occurred on 2/25/26 and was reported to the Department on 3/2/26 LPA met with Teacher Sofia Aquino whom the reason for the visit was explained. LPA went on a self-guided tour of the facility LPA observed preschool classroom area and outdoor play structure There are 13 children present and 1 lead teacher 1 campus supervisor and 1 aide. The facility was observed to be operating within the license capacity limitations.

On 3/2/26 an unusual incident report was made to the Department regarding a child injured by slipping and hit the middle of her legs. Teacher asked if child was ok she replied yes. Later as the child went to the restroom, Teacher noticed blood in the child underwear and called parent to pick up. An Ouch report was written and provided to parents at time of injury.

NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2026
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/CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 191597486
VISIT DATE: 04/08/2026
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Teacher Sofia disclosed that child was observed by medical professionals and returned to school on 3/2/26. Per teacher child is ok she was not prescribed any medication upon her arrival to school. Teacher explained the injury was more so from the flat shoes child was wearing which caused her to slip on the play structure. Teacher Sofia discussed with parent the importance of wearing tennis shoes while in care, parents have complied and children have been wearing appropriate shoes while in care. During LPA’s inspection of playground structure it is appropriate for ages 2-5. The structure was not wet at the time of injury teacher wipes it down every morning. Child who was injured is 5 years old and has great gross motor development per Teacher Sofia.

During today’s visit, LPA spoke with teacher Sofia, observed children eating snack in the preschool environment, reviewed sign in sheets and toured the classroom and outdoor play area.

Based on information obtained during the investigation, Policies and procedures were followed.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00

Exit interview conducted and report was reviewed with Sofia Aquino.

NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC809 (FAS) - (06/04)
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