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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 196216378
Report Date: 05/25/2023
Date Signed: 06/14/2023 10:19:02 AM

Document Has Been Signed on 06/14/2023 10:19 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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:KNOLLS LEARNING STUDIO - INFANT CENTER, THEFACILITY NUMBER:
196216378
ADMINISTRATOR:TRESSA MENDOZAFACILITY TYPE:
830
ADDRESS:28348 AGOURA ROADTELEPHONE:
(818) 991-7752
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 4TOTAL ENROLLED CHILDREN: 4CENSUS: DATE:
05/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tresssa MendozaTIME COMPLETED:
04:00 PM
NARRATIVE
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On 5/25/23, at 2:00 PM, Licensing Program Analyst (LPA) Elvin Baddley and LPA Giovani Gonzalez made an unannounced Case Management inspection to the aforementioned Child Care Center (CCC). LPAs met with Tressa Mendoza, Administrator of the CCC, and explained the nature of the inspection. LPAs notes 22 children in care at the time of the inspection.

The qualifications of staff members were reviewed. LPAs reviewed Personnel Files and note S1,S2,S3 and S5 do not have current Mandated Reporter certifications and S1,S2,S3,S4 and S5 are lacking Immunization records for T-Dap, MMR and Influenza.

A Type B Deficiency is being cited based on LPAs' observation/interviews/record reviews pursuant to Title 22 of the CA Code of Regulations (refer to LIC 809-D). Licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. A Notice of Site visit was given and must remain posted for 30 days.

A closing interview was conducted with Administrator. Administrator was provided and advised of their right to appeal. A copy of this report was reviewed and provided to the Administrator.

The Notice of Site Visit was also provided to the Administrator as required by H&S Code Section 1596.817. The Notice of Site Visit must remain posted for 30 days or a civil penalty of $100.00 may apply.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2023
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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Document Has Been Signed on 06/14/2023 10:19 AM - It Cannot Be Edited


Created By: Elvin Baddley On 05/25/2023 at 02:20 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: KNOLLS LEARNING STUDIO - INFANT CENTER, THE
FACILITY NUMBER: 196216378

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2023
Section Cited
HSC
1596.8662(b)(1)

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(1) On or before March 30, 2018, a person who, on January 1, 2018, ... licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training ...shall training every two years following...
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Administrator to submit Mandated Reporter Certification for all staff members lacking current certification to CCLD (elvin.baddley@dss.ca.gov) by 6/8/23.
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This requirement was not met as evidenced by the following: Records review revealed S1,S2,S3 and S5 failed to have current Mandated Reporter Certification. This poses at potential risk to the health, safety and personal rights of persons in care.
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Type B
06/08/2023
Section Cited
HSC1596.7995(a)(1)

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(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized... influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination...
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Administrator to submit current Immunization (T-Dap, MMR, Influ.) for all staff members to CCLD (elvin.baddley@dss.ca.gov) by 6/8/23.
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This requirement was not met as evidenced by the following: Records review revealed S1,S2,S3,S4 and S5 failed to have current Immunization (T-Dap, MMR, Influ.). This poses at potential risk to the health, safety and personal rights of 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:Maria Mueller
LICENSING EVALUATOR NAME:Elvin Baddley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023


LIC809 (FAS) - (06/04)
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