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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403646
Report Date: 10/07/2025
Date Signed: 10/08/2025 08:36:03 AM

Document Has Been Signed on 10/08/2025 08:36 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:ST. ELISABETH PRESCHOOLFACILITY NUMBER:
197403646
ADMINISTRATOR/
DIRECTOR:		LEEHAY, EMMAFACILITY TYPE:
850
ADDRESS:6635 TOBIAS AVE.TELEPHONE:
(818) 779-1766
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 50TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
10/07/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:26 AM
MET WITH:Jessica CruzTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On 10/7/2025 Licensing Program Analyst (LPA), Suzette Ornelas conducted unannounced annual inspection at the address mentioned above. LPA met with Center Director, Jessica Cruz and discussed the purpose of the visit. The Director guided LPA on a tour of the facility inside and out. Days and hours of operation are Monday through Friday 7:30am to 2:45pm.

LPA observed all required postings in a prominent area. LPA observed 5 children and 2 adults. All children are under supervision, including visual supervision, of a teacher at all times. Capacity and limitations as specified on the license are being maintained. A walk through of the classroom area was conducted. LPA observed 2 licensed preschool classrooms on the premises. All areas identified on the Facility Sketch were inspected. Due to low enrollment, Room 1 is not currently being used.Pre-School (Room 2)
RM 1: 0 children with a ratio of 0 teachers
RM 2: 5 children with a ratio of 2 teachers
A walk through of the classroom room space was conducted, the space was found to be clean and free from any potential hazards. Furniture was found to be in good repair and age appropriate. There is adequate heating, lighting and ventilation. Isolation area for sick students is in the Unused Room. LPA observed adequate arrangements for isolation and care of ill children.
The bathroom and toileting areas were inspected, LPA observed toilets and sinks to accommodate the facility’s capacity. Facility is equipped with 2 toilets and 2 sinks (1 toilet and 1 sink in each classroom). Toilets flush properly, toilet and sinks are reachable by the children in care. The restrooms have adequate toilet paper and paper towels available. The bathrooms were found to be clean. There is adequate lighting/ventilation in the bathroom area.
NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Suzette Ornelas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ST. ELISABETH PRESCHOOL
FACILITY NUMBER: 197403646
VISIT DATE: 10/07/2025
NARRATIVE
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Playground equipment is in safe condition and free of hazards. The surface of the outdoor activity space requires 2 holes to be repaired (rubber turf). Areas around high climbing equipment, swings and slides have cushioning material to absorb falls. There are 2 wooden doors on a shed accessible from the children's play area that were observed to be in need of repair. Wooden doors have paint chippings that require repair. All kitchen, food preparation and storage areas are clean and safe. Per Director, parents provide daily meals for children enrolled and school provides snacks. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is readily available both indoors and outdoors via children's individual refillable water containers and extra water available via water bottles located in the classroom. The facility is equipped with a working smoke detector and carbon monoxide detector. LPA observed fire extinguisher (2A10BC) located throughout the facility with service date of 3/5/2025. There is no swimming pool or other bodies of water on the premises. First Aid Kit was observed to be complete. Fire/Emergency Drill log was not observed current. There are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible. No poisons were observed during the inspection.

The facility has sufficient cots or mats for napping. Each mat or cot is occupied by only one child at time. LPA reviewed a sample of children’s files and observed files were complete. Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review have received a criminal record clearance or exemption. CPR and Pediatric First Aid certificates were observed current (10/31/2023). The name of the child care center director or fully-qualified teacher(s) designated to act in the director’s absence has been reported to the Department. LPA reviewed a sample of staff files and observed files were incomplete, all staff need to obtain Mandated reporter Training (AB1207) Certificate. Proof of MMR, Tdap and TB immunization's.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Suzette Ornelas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ST. ELISABETH PRESCHOOL
FACILITY NUMBER: 197403646
VISIT DATE: 10/07/2025
NARRATIVE
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LPA and Administrator discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Administrator was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Administrator was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, 7 type B deficiencies are cited. (See LIC809-D)


This report shall be made available to the public upon request. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director, Jessica Cruz.
NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Suzette Ornelas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2025 08:36 AM - It Cannot Be Edited


Created By: Suzette Ornelas On 10/07/2025 at 02:30 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ST. ELISABETH PRESCHOOL
FACILITY NUMBER: 197403646

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101169(d)(18)
Application for License
(18) Evidence that the applicant has posted signs at the entrance to the child care center that provide the telephone number of the local health department and information on child passenger restraint systems pursuant to Health and Safety Code section 1596.95(g) and Vehicle Code sections 27360 and 27360.5.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in sign not posted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Director will provide proof to LPA via email.
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in drill documentation unavailable which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Director will provide proof to LPA via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Suzette Ornelas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2025 08:36 AM - It Cannot Be Edited


Created By: Suzette Ornelas On 10/07/2025 at 02:30 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ST. ELISABETH PRESCHOOL
FACILITY NUMBER: 197403646

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238.2(d)(2)
Outdoor Activity Space
(d) The surface of the outdoor activity space shall be maintained: (2) Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in play area turf is in need of repair (3holes) and 2 wooden doors chipped paint, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Director will provide proof to LPA via email.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Mndated reporter training (AB1207) not completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Director will provide proof to LPA via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Suzette Ornelas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2025 08:36 AM - It Cannot Be Edited


Created By: Suzette Ornelas On 10/07/2025 at 02:30 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ST. ELISABETH PRESCHOOL
FACILITY NUMBER: 197403646

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(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:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in MMR, TDAP, not available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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Director will provide proof to LPA via email.
Type B
Section Cited
CCR
101215.1(b)
Child Care Center Director Qualifications and Duties
(b) All child care centers shall have a director.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Director packet has not been submitted to the department, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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Director will provide proof to LPA via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Suzette Ornelas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2025 08:36 AM - It Cannot Be Edited


Created By: Suzette Ornelas On 10/07/2025 at 02:30 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ST. ELISABETH PRESCHOOL
FACILITY NUMBER: 197403646

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in TB not readily available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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3
4
Director will provide proof to LPA via email.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Suzette Ornelas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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