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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601484
Report Date: 02/27/2024
Date Signed: 02/27/2024 02:57:54 PM

Document Has Been Signed on 02/27/2024 02:57 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:UCLA EARLY CARE AND EDUCATIONFACILITY NUMBER:
191601484
ADMINISTRATOR:AMY AGNEWFACILITY TYPE:
850
ADDRESS:101 S. BELLAGIO DR.TELEPHONE:
(310) 825-5086
CITY:LOS ANGELESSTATE: CAZIP CODE:
90095
CAPACITY: 122TOTAL ENROLLED CHILDREN: 122CENSUS: 78DATE:
02/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Alicia Minor, Center DirectorTIME COMPLETED:
03:05 PM
NARRATIVE
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Regional Manager (RM) Victor Bautista, Rita Ramos, Licensing Program Manager I, and Licensing Program Analyst (LPA) Lilia Hernandez conducted an unannounced case management inspection due to an incident that occurred on 12/15/2023. The Department arrived at the facility at 1:46PM and met with Alicia Minor, who guided LPA on a tour of the facility. There were 78 children and 15 staff present upon arrival.

The incident that occurred on 12/15/2023, was reported to the Department on 12/18/2023, via telephone. The facility reported the Unusual Incident to the Department within the required 24 hours of occurrence.

Information reported to the Department indicated that Staff #2 may or may not have violated the personal rights of Child# 1.

Documentation obtained from the facility indicated that Staff #1 observed Staff #2 with their head, torso and arm on Child #1. Child#1 spontaneously disclosed the incident to Staff #1 and Staff #3.

Based on interviews, and written statements provided, it was determined that the personal rights of child #1 were violated when Staff #2 was observed with their head, torso and arm on Child#1. This was an immediate risk to the health and safety of children in care.

The following deficiencies listed on the attached LIC 809D are being cited in accordance with California Code of Regulations Title 22.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. ---Page 1 of 2
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: UCLA EARLY CARE AND EDUCATION
FACILITY NUMBER: 191601484
VISIT DATE: 02/27/2024
NARRATIVE
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A copy of the LIC 9224 - Acknowledgement of Receipt of Licensing Reports was provided during this visit.

The Notice of Site Visit was given and must remain posted for 30 days during the hours of operation after each site visit by a licensing representative.

Exit interview was conducted and report was reviewed with Alicia Minor, Center Director.

---Page 2 of 2
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/27/2024 02:57 PM - It Cannot Be Edited


Created By: Lilia Hernandez On 02/27/2024 at 02:07 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: UCLA EARLY CARE AND EDUCATION
FACILITY NUMBER: 191601484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/27/2024
Section Cited
HSC
1596.8897(a)(2)

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Prohibited positions or employment; grounds; notice; removal; appeal; petition for reinstatement, (a)(2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility... This Requirement is not met as evidenced by:
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Facility was provided with an order to Licensee/Facility of Immediate Exclusion from Facility. Center Director will be providing a refresher on Mandated Reporting Training and review of Personal Rights.
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Based on observation, interview and record review, Investigations revealed that S2 was observed by S1, laying on top of C1 covering their torso, which poses an immediate or Health and Safety, and personal rights risk to persons in care.
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Type A
02/27/2024
Section Cited
101123(a)(3)

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Personal Rights, (a)(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to...
This Requirement is not met as evidenced by:
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Per Center Director, S2 was placed on administrative leave on 12/18/2023. Center Director will be providing a refresher on Mandated Reporting Training and review of Personal Rights.
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Based on observation, interview and record review, Investigations revealed that C1 approached S1, S3 and spontaneously disclosed that S2 was laying on top of them, and they did not like it, which poses an immediate or Health and Safety, and 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:Rita Ramos
LICENSING EVALUATOR NAME:Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024


LIC809 (FAS) - (06/04)
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