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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197402297
Report Date: 04/07/2022
Date Signed: 04/07/2022 02:05:26 PM

Document Has Been Signed on 04/07/2022 02:05 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:GATES STREET ELEMENTARY SCHOOL ROOM 5FACILITY NUMBER:
197402297
ADMINISTRATOR:ROBLES, MARICELA SANCHEZFACILITY TYPE:
850
ADDRESS:3333 MANITOU AVENUETELEPHONE:
(323) 225-9574
CITY:LOS ANGELESSTATE: CAZIP CODE:
90031
CAPACITY: 23TOTAL ENROLLED CHILDREN: 0CENSUS: 11DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Angela Rangel, Campus Aide, Tammy She, Teacher & Omar Malaszczuk, PrincipalTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Mireya Garcia conducted an unannounced Annual Required Inspection. LPA met with Campus Aide, Angela Rangel, who guided LPA on a tour of the facility indoors and outdoors. Principal, Omar Malaszczuk was not available during LPA arrival. This is an LAUSD state preschool program located in RM 5 on the premises of Gates Elementary School. The program consists of one (1) classroom; Room 5. This program operates 2 sessions from Monday through Friday. There is an AM session that operates from 7:40AM to 10:40AM. The PM session operates from 11:00AM to 2:00PM. This facility has a capacity of 23 children; preschool children ages 2.9 to 5 years old.

Upon LPA arrival there were eleven (11) preschoolers present in the outdoor play yard with Staff #1, #2 and #3. Teacher-child ratio is met. All individuals present have obtained a criminal record clearance or criminal record exemption. All staff have received an active criminal record clearance as a condition of their employment with the Los Angeles Unified School District. All children were observed to be under visual supervision of a teacher at all times.

REPORT CONTINUES ON NEXT PAGE 1 OF 5.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GATES STREET ELEMENTARY SCHOOL ROOM 5
FACILITY NUMBER: 197402297
VISIT DATE: 04/07/2022
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LPA observed the facility to be clean, safe, sanitary and in good repair. Furniture and equipment were inspected for good repair, free of sharp, loose, or pointed parts. Indoor classroom was inspected to ensure that the floor has a surface that is safe and clean. All toilets and hand washing facilities are in safe and sanitary operating conditions. All materials and surfaces accessible to children are toxic free. At this time, the Nurse’s office is used as an isolation area. There are chairs and a clinical bed in the office. Parents are contacted immediately when children are determined to be ill and staff are ensuring that children with obvious symptoms of illness are not being accepted.

Snack menus were reviewed to ensure that they are being posted at least one week in advance and visible to an authorized representative. Preschoolers are provided with Breakfast for the AM session and Lunch for the PM session by the Los Angeles Unified School District. All kitchen, food preparation, and storage areas are clean, free of litter, rubbish, and rodents/vermin. All food is protected from contamination, and LPA inspected that any contaminated food is discarded immediately. There is drinking water available in all indoor classrooms (water bottles) and water bottles were observed outdoors. All storage containers for solid waste, including moveable bins, have tight fitting covers on and are in good repair. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are stored in an area inaccessible to children. Teacher, Tammy She states that there are no poisons stored at the facility.

REPORT CONTINUES ON NEXT PAGE 2 OF 5.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GATES STREET ELEMENTARY SCHOOL ROOM 5
FACILITY NUMBER: 197402297
VISIT DATE: 04/07/2022
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Facility has one functioning carbon monoxide detector that meets statutory requirements. The carbon monoxide detector is located inside Room 5, which was tested at 8:43 am, and it is in operable condition. The facility representative takes measures to keep the facility free of flies, other insects and rodents.

Outdoor play equipment was observed to be in good condition, free of sharp, loose or pointed parts. Outdoor activity space surface is maintained in a safe condition as is free of hazards. The Teacher states that there are no bodies of water on the premises and LPA did not observe any bodies of water during this visit. Areas around and/or under climbing equipment and slides have soft cushioning to absorb a fall.

Sign in and out sheets were reviewed by LPA to ensure that children who are present where sign in. Staff Records were not available for review. Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. LPA issued the Children’s Record Review (LIC 857) and the Review of Staff records (LIC 859) to the Principal during this inspection. Pediatric CPR/First Aid and health preventative practices documentation were not available for review.



SB792 (Immunization Requirements for Staff and Employees) was discussed with the facility representative.

REPORT CONTINUES ON NEXT PAGE 3 OF 5.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GATES STREET ELEMENTARY SCHOOL ROOM 5
FACILITY NUMBER: 197402297
VISIT DATE: 04/07/2022
NARRATIVE
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AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers

Incidental Medical Services (IMS) policy was discussed. Per Teacher Tammy the facility currently has no children enrolled who require any medication. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm


The following was discussed:
· Reporting Requirements.
· The facility shall ensure that each child is accorded the following personal rights: to be accorded safe, healthful and comfortable accommodations.
· All personnel shall be in good health and shall be physically and mentally capable of performing assigned tasks; personnel that pose a threat to the health and safety of children shall be relieved of their duties.
· All personnel shall be given on the job training in housekeeping, sanitation principles and universal health precautions.

REPORT CONTINUES ON NEXT PAGE 4 OF 5.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GATES STREET ELEMENTARY SCHOOL ROOM 5
FACILITY NUMBER: 197402297
VISIT DATE: 04/07/2022
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LPA advised the facility representative to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D for deficiencies that are being cited and needs to be cleared to protect the children’s health & safety.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with facility representative, Omar Malaszczuk.

REPORT ENDS HERE PAGE 5 OF 5.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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Document Has Been Signed on 04/07/2022 02:05 PM - It Cannot Be Edited


Created By: Mireya Garcia On 04/07/2022 at 01:03 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: GATES STREET ELEMENTARY SCHOOL ROOM 5
FACILITY NUMBER: 197402297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
HSC
1596.7995

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1596.7995:Employees or volunteers at day care center; immunization requirements; records; exemptions- (a) (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 against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
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Per Principal, copies of immunization records for Staff #1, #2, #3 and #4 will be submitted to LPA Garcia via email by POC due date of 04/29/2022.
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LPAs interview disclosures from Principal and Staff that immunization (pertussis, measles, and influenza) records for Staff #1, #2, #3, and #4 are not available for review.This poses a potential health and safety risk to children in care.


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Type B
04/29/2022
Section Cited
CCR101215.1(m)

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 Child Care Center Directors Qualifications and Duties- (m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
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Per Principal, record copies for 16 hours of health and safety training will be submitted to LPA Garcia via email by POC due date of 04/29/2022.
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LPAs interview disclosures from Principal, records for 16 hours of health and safety training from Principal are not available for review. This poses a potential 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.
SUPERVISOR'S NAME:Brandi VanOosten
LICENSING EVALUATOR NAME:Mireya Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


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Document Has Been Signed on 04/07/2022 02:05 PM - It Cannot Be Edited


Created By: Mireya Garcia On 04/07/2022 at 01:17 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: GATES STREET ELEMENTARY SCHOOL ROOM 5
FACILITY NUMBER: 197402297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
101216(f)

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101216-Personnel Requirements:
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities. This requirement is not met as evidenced by:
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Per Principal, copies of Pediatric cardiopulmonary resuscitation and pediatric first aid training certificate will be submitted to LPA Garcia via email by POC due date of 04/29/2022.
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LPAs interview disclosures from Principal and Staff that proof of pediatric cardiopulmonary resuscitation and pediatric first aid training is not available for review.This poses a potential health and safety risk to children in care.
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Type B
04/29/2022
Section Cited
CCR101217(d)

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101217-Personnel Records:(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
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Per Principal, staff records will be made available for the future, Principal will submit record review of Staff #1, Staff #2, Staff #3, and Staff #4 to LPA Garcia via email by POC due date of 04/29/2022.
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LPAs interview disclosures from Principal and Staff that staff records for Staff #1, #2, #3, and #4 are not available for review.This poses a potential 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.
SUPERVISOR'S NAME:Brandi VanOosten
LICENSING EVALUATOR NAME:Mireya Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


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