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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191890273
Report Date: 05/19/2025
Date Signed: 05/19/2025 02:32:11 PM

Document Has Been Signed on 05/19/2025 02:32 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:ALBION STREET EARLY EDUCATION CENTERFACILITY NUMBER:
191890273
ADMINISTRATOR/
DIRECTOR:		CAROLYN MACARANASFACILITY TYPE:
850
ADDRESS:348 SOUTH AVE. 18TELEPHONE:
(323) 221-1798
CITY:LOS ANGELESSTATE: CAZIP CODE:
90031
CAPACITY: 115TOTAL ENROLLED CHILDREN: 55CENSUS: 45DATE:
05/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Office Manager, Xiomara BarriereTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On Monday, May 19, 2025, Licensing Program Analyst (LPA’s) Staicy Perry and Joanne Solorio-Campos conducted an unannounced case management inspection for a follow up visit to the above facility. Upon arrival LPA’s met with Office Manager, Xiomara Barriere who guided LPA’s on a tour of the facility. The purpose of the inspection is to deliver the findings regarding an incident reported to the regional office. Census was taken. LPAs observed 45 children at the time of inspection.

The department received an incident report via phone from this facility on Tuesday April 22, 2025 for an incident that occurred at the facility on Tuesday April 22, 2025 involving a child in care who wandered off the facility premises. The incident was reported to the department in a timely manner according to Title 22 Regulations.

During the course of the investigation, LPA Perry conducted interviews with facility staff, obtained declarations, photos, measurements, and obtained copies of relevant documentation including but not limited to the facilities ECE Parent Handbook and LAUSD Parent Handbook 2024-2025.

Interviews were conducted regarding the above incident. All staff confirmed that the incident occurred around 11:00 AM. It was consistently reported that several entry and exit points including the main entrance gate, the gate leading into the facility, and the parking lot gate were left open at that time. Staff #4 indicated they left the parking lot gate open upon arrival, assuming that an aide who was leaving and getting into their vehicle would close it. Staff #2 acknowledged that this action did not align with facility policy, which requires the parking lot gate to remain closed during operating hours. Staff also confirmed that all other gates and doors, such as the front gate and entrance door, are required to always remain closed for safety reasons.

Additionally, Staff #1 explained that the doors were left open during the incident to ease the process of moving items in and out of the facility. All staff interviewed confirmed that training on child supervision had

NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Staicy Perry
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
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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Document Has Been Signed on 05/19/2025 02:32 PM - It Cannot Be Edited


Created By: Staicy Perry On 05/19/2025 at 01:41 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: ALBION STREET EARLY EDUCATION CENTER
FACILITY NUMBER: 191890273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2025
Section Cited
CCR
101223(a)(2)

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101223 Personal Rights: (a) The licensee shall ensure that each child is accorded the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:
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Principal conducted a meeting and training regarding incident. Per Principal they will submit a copy of agenda and signing sheet to LPA by POC Due Date
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Based on information obtained during this investigation, the licensee did not comply in the section above which facility failed to provide a safe environment which caused C#1 who wandered off the facility premises. This poses an immediate health and safety risk to children 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.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Staicy Perry
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


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: ALBION STREET EARLY EDUCATION CENTER
FACILITY NUMBER: 191890273
VISIT DATE: 05/19/2025
NARRATIVE
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been completed and emphasized that the child involved in the incident was always under supervision. Staff consistently reported that at no point was the child left unsupervised.

The information gathered during the interviews highlights a lapse in adherence to established safety protocols, particularly concerning the facility’s access points. Based on interviews, there was no indication of a lack of supervision; however, the child did manage to exit the facility and not provided a safe environment. The child reportedly ran approximately 590 feet, the child crossed Mozart and 19th Street, a one-way stop intersection (Avenue 19) and eventually making it to home. The child was not injured during the incident. The child was able to exit the facility due to multiple facility doors being open, which allowed for unobstructed access outside. Staff members were reported to be following behind the child immediately upon exit and in visual at all times.

This agency has investigated the incident reported that a child in care wandered off the facility premises which an immediate risk to the health and safety of the children in care. The deficiency listed on the following page was observed by LPA Perry and is being cited in accordance with California Code of Regulations Title 22. One type A deficiency is being issued today for regulation 101223 (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. Please see attached LIC 809-D for citation.



Deficiencies that are being cited need to be cleared to protect the children’s health & safety. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon their return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled child for the next 12 months. A signed Acknowledgement of Receipt (LIC9224) shall be in each child’s file, acknowledging receipt.

Notice of site visit was provided. Exit interview was conducted with Office manager Xiomara. Appeal Rights were discussed and provided.

NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Staicy Perry
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
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