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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870577
Report Date: 08/20/2025
Date Signed: 08/20/2025 11:32:17 AM

Document Has Been Signed on 08/20/2025 11:32 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 SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:WILLOWBROOK CHILD DEVELOPMENT CENTERFACILITY NUMBER:
191870577
ADMINISTRATOR/
DIRECTOR:		LUCY BRYANTFACILITY TYPE:
850
ADDRESS:12829 SO. JARVIS AVE.TELEPHONE:
(310) 352-4486
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 73TOTAL ENROLLED CHILDREN: 43CENSUS: 44DATE:
08/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:19 AM
MET WITH:ADMINISTRATOR /LUCY BRYANTTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Calderon arrived at the facility unannounced for the purpose of a Case Management Incident. LPA met with Secretary Kartherine Castillo whom informed Administrator Lucy Bryant of LPA's arrival. LPA disclosed purpose of today's visit.

LPA Calderon conducted a tour of the facility with Administrator L.Bryant. Classrooms observed (4); calssrooms were in ratio and facility was in compliance with their license. LPA took census during tour and census was (44) children and (10) teachers present. LPA toured and observed the area that Child #1 fell. Area Child #1 fell is the blue/black cushioned material located in the main play yard, LPA observed no hazardous risk/danger in outdoor play area were incident took place.

During this visit LPA attempted to interview teacher and teacher assistant whom were in the classroom on 8/12/25 when incident took place with Child #1, both teachers were not present during today's visit. Child #1 based on Unusual Incident Report (UIR) was playing with a classmate and fell when running and landed on another child. Lead Teacher in Child #1 classroom observed both children for any signs of injury. Child #1 stated they were hurt. Per Site Supervisor interview, Child #2 was not hurt. LPA Calderon interviewed Child #2 during visit, child informed LPA Calderon Child #1 fell because they were running fast and when asked were did Child #1 get hurt they pointed to the arm area. Child #2 when asked how they are feeling stated okay and when LPA asked Child #2 where area did Child #1 get hurt they stated outside.

The school based on UIR followed appropriate procedures to contact Child #1 guardian to inform parent of accident when child stated they are hurt, parents came to pick up child and school's internal accident report was given on 8/12/25 to parent. (cont..)
NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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 SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: WILLOWBROOK CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 191870577
VISIT DATE: 08/20/2025
NARRATIVE
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LPA during visit collected: Accident Report dated 8/12/25 signed by Child #1 Guardian and states body part involved in accident - right arm and Medical Test Result and School Status Report was collected. Child #1 was instructed not to attend school from 8/12/25 - 8/29/25 per School Status Report by their doctor. Per MD's test results Child #1 was examined, report states child shoulder was injured. Per L.Bryant followed up with Child #1 guardian on 8/19/25, whom stated doctor's are doing more testing as they think it is an injury to the elbow and not the shoulder, child #1 is having further testing's done.

Parent of Child #1 reported to the school per UIR -LIC624 under the section titled medical treatment that mom came back to school on 8/13/25 with doctor's report. The Department received the reported UIR from the facility on 8/19/25, the reporting requirement was not reported in a timely manner accordance to California Code of Regulation Title 22, deficiency cited.

During this visit, per California Code of Regulation Title 22, facility was given (1) deficiency on LIC809-D regarding reporting requirement for an injury to any child that requires medical treatment.

A notice of site visit was given, must be posted for 30 days. An exit interview was conducted with Administrator Lucy Bryant and report with appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2025 11:32 AM - It Cannot Be Edited


Created By: Ashley Calderon On 08/20/2025 at 11:00 AM
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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: WILLOWBROOK CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 191870577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2025
Section Cited
CCR
101212(d)(1)(B)

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(d) Upon the occurrence, during the operation...of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report...submitted to the Department within
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LPA Calderon provided regulation 101212 Reporting Requirements and video on the CCLD website on Child Care Reporting Requirement .
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seven days following the occurrence of such event. (B) Any injury to any child that requires medical treatment.
The requirement was not met as evidenced by: Facility was informed of injury required medical treatment on 8/13/25 and reporting to the dept. on 8/19/25.
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 Administrator Lucy Bryant will write 3 things they learned regarding reporting requirement on the LIC855 Declaration Letter and submit to LPA Caldeon via email by poc due 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.
Denise Gibbs
NAME OF LICENSING PROGRAM MANAGER:
Ashley Calderon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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