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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191890452
Report Date: 07/14/2026
Date Signed: 07/14/2026 03:58:13 PM

Document Has Been Signed on 07/14/2026 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:VINE STREET EARLY EDUCATION CENTERFACILITY NUMBER:
191890452
ADMINISTRATOR/
DIRECTOR:
SHARON HARRISFACILITY TYPE:
850
ADDRESS:6312 ELEANOR AVENUETELEPHONE:
(323) 465-1167
CITY:LOS ANGELESSTATE: CAZIP CODE:
90038
CAPACITY: 198TOTAL ENROLLED CHILDREN: 56CENSUS: 39DATE:
07/14/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Armando Inclan, Principal TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Roxana Lopez conducted an unannounced Subsequent Case Management- Incident inspection on this date to follow up on 8 incident reports that were reported to the Department on 1/23/2026, 3/10/2026, 3/16/2026, 3/17/2026, 3/24/2026, 3/25/2026 and 4/15/26. LPA met with Principals Armando Inclan and ALlison Speight who the purpose of the inspection was announced to. Per Principal there are 56 children enrolled. Census was taken.

1. On 1/23/2026 (incident # 1) the facility reported that staff #1 and staff # 2 witnessed staff # 3 violating child # 1 and child # 2 personal rights.
2. On 3/10/2026 (incident # 2) the facility reported that parent of child # 3 had concerns regarding child's # 3 diapering needs.
3. On 3/16/2026 (incident # 3) the facility reported an incident regarding child # 4 falling and requiring medical attention
4. On 3/17/2026 (incident # 4) the facility reported that parent of child # 5 disclosed their child's personal rights being violated by staff # 4.
5. On 3/24/2026 (incident # 5) the facility reported that they received communication from LAUSD Transportation that parent alleges that their child's (child # 7) personal rights were violated by staff # 6
6. On 3/25/2026 (incident # 6) the facility reported an incident regarding child # 8 falling and requiring medical attention.
7. On 4/15/2026 (incident # 7) the facility reported Principal updates ------------ pg. 1 of 5 ---------------
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Roxana Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2026
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: VINE STREET EARLY EDUCATION CENTER
FACILITY NUMBER: 191890452
VISIT DATE: 07/14/2026
NARRATIVE
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Regarding incident # 1 interviews were conducted with staff, children and parents. Per initial report Staff # 1 and # 2 observed staff # 3 shaking and yelling at child # 1 and child # 2. Written statements were obtained from both staff # 1 and # 2. Staff # 1 disclosed that they observed Staff # 3 shaking and yelling at child # 1 and when they asked them to stop staff # 3 threw a chair out of anger and stated that child # 1 had hit them - staff # 3 then proceeded to another area of the classroom and was observed shaking child # 2.

Staff # 2 disclosed that they wrote a statement of their observation on 1/23/2026 but on 4/8/26 during interview with Staff # 2, they recanted their statement and is now saying their reporting of the incident was “an accident.” Staff # 1 disclosed that staff # 2 was present and observed the same incident. Per staff # 1- staff # 2 stated that they would be writing a statement as well. Child # 1 disclosed that Staff # 3 gets mad and yells. Parent of child # 1 disclosed that they were informed of the incident and when they asked child # 1 what happened child # 1 disclosed that staff # 3 had shaken and yelled at them because they were mad. When parent asked child # 1 why was staff # 3 mad child # 1 disclosed that they had hit staff # 3. No disclosures were made by child # 2 or parents of child # 2.

Regarding incident # 2 interviews were conducted with staff and parents. Per initial report parent of child # 3 had concerns of child’s diapering needs. During interview staff # 4 disclosed that in the afternoon classrooms are combined, and diapers are changed before pick up. Staff # 4 disclosed that aides change diapers and staff # 5 has refused to change diapers, several times- therefore they look for coverage from other aides or administration to be able to meet the children’s needs. Other staff interviews corroborated that they have observed or heard staff # 5 refuse to change diapers. Per Staff # 5 they have never refused to change a diaper. LPA obtained a copy of the diapering policies that states that "education aides are responsible for diaper/pull up changes and toileting procedures and teachers are also responsible to take students to the restroom and monitor restroom procedures. During parent interviews- 2 parents disclosed that their child’s diapering needs have not been met several times, and this happened in the afternoon when classrooms are combined.
Regarding incident # 4 interviews were conducted with staff, parents and children. --- pg. 2 of 5 --
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Roxana Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
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: VINE STREET EARLY EDUCATION CENTER
FACILITY NUMBER: 191890452
VISIT DATE: 07/14/2026
NARRATIVE
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Per initial report facility reported that parent alleges that their child’s (child # 5) personal rights were violated by staff # 4. Per staff interviewed they have observed staff # 4 be a little rough with children as staff # 4 grabs children’s arm to talk to them. Per children interviewed no disclosures were made and they like staff # 4. Child # 5 is not attending school at this time. Per parent of child # 5 after discussing the issue with administration their child has not shared any other concerns situations of being hurt by staff # 4.

LPA determined Children’s personal rights were violated in incidents # 1, 2 and 4 which is an immediate risk to children in care. Incident # 1 interviews disclosed that staff # 1 shook and yelled at child # 1 and # 2. Incident # 2 interviews disclosed that staff # 5 refuses to change diapers and parents corroborated they have concerns regarding diapering needs as their children have gone home with dirty diapers. Incident # 4 interviews disclosed that staff # 4 is rough with children and grabs them when talking to them.

Regarding incident # 3 interviews were conducted with staff. Per initial report facility reported that child # 4 had fallen hurting the back of their head- incident was not observed, ambulance was called. Staff interviews corroborated that table where child # 4 was sitting at was not supervised. Child # 4 was running around the class- then child began to cry. Per staff it seemed like child fell off the chair as child was laying on the floor next to the chair- but incident was not directly observed. Ambulance was called to check on child. Per staff child was not transported and was picked up by parents. Staff interviewed corroborated that there was no adult in the area where the incident happened- staff did not recall who was supposed to be supervising that area.

Based on interviews and documentation reviewed it was determined that Incident # 3 was determined to be lack of supervision as there was no staff member supervising the table where child fell, per staff no one observed the incident directly and they were not aware on who should have been supervising table.

Regarding incident # 5 interviews were conducted with staff. Per initial report the facility reported that that they received communication from LAUSD -------------------- pg. 3 of 5 -------------------------------
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Roxana Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
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: VINE STREET EARLY EDUCATION CENTER
FACILITY NUMBER: 191890452
VISIT DATE: 07/14/2026
NARRATIVE
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Transportation that parent alleges that their child's (child # 6) personal rights were violated by staff. An investigation was conducted by the facility no disclosures were made by child. LPA conducted interviews with staff # 6. Per staff they were covering that bus route- they picked up child from facility- helped child sit on seat and placed the seatbelt on. Drive was approximately 5 minutes- they helped child # 6 off the seat and the bus, verified ID and released child. Per parent of child # 6- during pick up their child seemed off and wouldn’t disclosed anything at first- but then pointed outside to the bus and after asking questions child # 6 disclosed being punched twice and armed being pulled. LPA was not able to interview child # 6 as child is no longer attending facility and parent did not contact LPA for interview.

Regarding incident # 5 based on interviews conducted LPA was not able to determined if child # 6 personal rights were violated.

Regarding incident # 6 interviews were conducted with staff. Per initial report the facility reported that child # 7 had fallen off an adult table/bench, hitting the back of their head, requiring medical attention and parents were notified approximately 2 hours after incident. Per staff # 7 and # 8 incident was observed- children were playing on the adult table with magnet tiles, when child # 7 fell back- staff # 7 and # 8 were on the opposite side of the table. Per staff # 8 they observed child fall and staff # 7 helped child right away by picking up child and provided ice- however they are not sure when parents were called as staff # 8 was taking care of the situation. Per staff # 7 they observed incident and helped child right away by helping child up and providing ice. Per staff # 7 they were unable to call parents or notified administration at that time as other staff were on break and they were maintaining ratio, therefore they couldn’t step away to call. Per staff # 7 they do not have walkie talkies to communicate with administration. Additionally, staff # 7 disclosed that they did not observed any bumps on child and kept observing child until parents were called. Per interviews conducted incident occurred around 10:45 am and parent were not called until approximately 2 hours later. Interviews disclosed two calls were made- First call was to inform parents of head injury and that child # 7 was okay----------------------- pg. 4 of 5 ----------------------------------------------------------------
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Roxana Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC809 (FAS) - (06/04)
Page: 5 of 9
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: VINE STREET EARLY EDUCATION CENTER
FACILITY NUMBER: 191890452
VISIT DATE: 07/14/2026
NARRATIVE
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second call within minutes was made to ask parent to pick child up and take them to the doctor. Parent interview disclosed that they had previously shared concerns regarding this table- additionally parent corroborated they were informed that injury happened at 10:45 am but were not called until 2 hours later. When called was made parent noticed that call was made via a personal number and not the facility number.

Regarding incident #7 interviews were conducted by staff. Per initial report the facility did not report Principal updates- interim principals have been covering since March of 2026. This incident was not reported within the required 10 days.

Incidents # 5 and #7 were determined that facility did not follow reporting requirements under title 22. Incident # 5 was not reported to parents immediately and Incident # 7 was not reported to the department within 10 days

The following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.
LPA Roxana Lopez informed facility representative Principal's Armando Inclan and Allison Speight that this report dated 7/14/26 document(s) (1) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Roxana Lopez informed the facility representatives to provide a copy of this licensing report dated 7/14/26 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the facility representative Armando Inclan & Allison Speight --pg.5 of 5
NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Roxana Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/14/2026 03:58 PM - It Cannot Be Edited


Created By: Roxana Lopez On 07/14/2026 at 12:34 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: VINE STREET EARLY EDUCATION CENTER

FACILITY NUMBER: 191890452

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2026
Section Cited
CCR
101223(a)(3)

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101223 Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (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...
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Per Principals- they have memos and policies in place. They will meet with staff regarding personal and will follow staff relations. Copies of agenda- meeting minutes and sigining sheets.
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This requirement was not met as evidence by: Based on interviews conducted the Licensee did not comply with section cited above in that Staff # 3, Staff # 4 and Staff # 5 violated personal rights of child # 1, # 2, # 3 and # 5 in different incidents which poses an immediate risk for 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:
Roxana Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2026 03:58 PM - It Cannot Be Edited


Created By: Roxana Lopez On 07/14/2026 at 12:39 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: VINE STREET EARLY EDUCATION CENTER

FACILITY NUMBER: 191890452

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2026
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. 1. No child(ren) shall be left without the supervision of a teacher at any time… This requirement was not met as evidence by:

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Per Principal they will conduct a meeting with staff- regarding active supervision. Meeting minutes, agenda and sign in sheets will be submitted to LPA by 8/3/26.
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Based on interviews the licensee did not comply with section above in that Staff interviews corroborated that child # 4 fell and hit their head- incident was not observed and staff did not know who was supervising that area. This is posed/poses a potentail risk for children in care
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Type B
08/03/2026
Section Cited
CCR101226(a)

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B: 101226 Health-Related Services (a) The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch... This requirement is not met as evidenced by:
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Per Pricipal they will meet with staff regarding reporting to authorize representatives- and incidents, Meeting minutes, agenda and sign in sheetes will be submited by poc due date of 8/3/26
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Based on interviews the licensee did not comply with section above in that Staff interviews corroborated that child # 7 fell at approximately 10:45 am and authorized representatives were not called until 2 hours after. This posed/poses a potential risk for 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:
Roxana Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 07/14/2026 03:58 PM - It Cannot Be Edited


Created By: Roxana Lopez On 07/14/2026 at 12:54 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: VINE STREET EARLY EDUCATION CENTER

FACILITY NUMBER: 191890452

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2026
Section Cited
CCR
101212(b)

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101212 Reporting Req. Each licensee or applicant shall furnish to the Dept. reports as required by the Dept. including... (b) The name of the child care center director... designated to act in the child care center director's absence, shall be reported to the Deptt within 10 days...
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Per Principal- report was submitted during insspections. Packet of new principal will be submitted to LPA by 8/3/26.
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This requirement was not met as evidenced by: Based on observation- interviews and records review the Licensee did not comply with section above as they did not report the change of Principal withen the required time. This posed/poses a potential risk for 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:
Roxana Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2026


LIC809 (FAS) - (06/04)
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