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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197408763
Report Date: 08/23/2021
Date Signed: 08/23/2021 05:03:12 PM

Document Has Been Signed on 08/23/2021 05:03 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:WEST HOLLYWOOD CHILDREN'S ACADEMYFACILITY NUMBER:
197408763
ADMINISTRATOR:JOULIANA BARANOVAFACILITY TYPE:
850
ADDRESS:1030 N. VISTA STREETTELEPHONE:
3107481656
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 35TOTAL ENROLLED CHILDREN: 0CENSUS: 27DATE:
08/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jouliana Baranova, Director/Licensee TIME COMPLETED:
01:30 PM
NARRATIVE
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On 8/23/2021 at approximately, 11:30am, Licensing Program Analysts (LPAs) Denise Miranda and Judy Laureano conducted an announced case management. LPAs were greeted by Teacher Assistant Beatriz Echeverria and Sub-Teacher Roghayeh Harsini. At 8:33am LPAs observed Director arrived at the facility and discussed the purpose of the inspection. LPAs observed 7 children and around 8:50am 10 children were present. Around 12:00pm LPAs observed 27 children in care with 5 staff and Director.

While conducting the case management inspection, LPAs observed all children in care without mask.

LPAs observed all staff in the facility wearing mask. LPAs discussed the mask recommendation reference in the Guidance for Early Childhood Education Providers Requirements, and Best Practices provided by the department of health.

http://publichealth.lacounty.gov/media/Coronavirus/docs/education/GuidanceEarlyChildhoodEducation.pdf



During this inspection, Director confirmed that a positive COVID-19 case was reported to the facility on 8/3/2021 and Director did not report to Department of Social Services.

Two Advisories notes was provided to Director. The written Unusual Incident Report (LIC624), shall submit via email, or fax (424) 301-301-3200 no later than tomorrow 8/24/2021.

In addition, the following deficiencies were observed in accordance to Title 22 of the California Code of Regulations and Health and Safety Codes during this inspection. Please refer to 809-D for documentation of deficiencies.

Notice of visit, with two Advisories was provided to director with a copy of the report.
SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 08/23/2021 05:03 PM - It Cannot Be Edited


Created By: Denise Miranda On 08/23/2021 at 12:17 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: WEST HOLLYWOOD CHILDREN'S ACADEMY
FACILITY NUMBER: 197408763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2021
Section Cited
CCR
10126.3(a)(b)

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Prescription medications may be administered if all of the following conditions are met: (A)Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. (B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized
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Per Director, chid#1 and Chil#2 will not return to school until parents provide the epipen for child#1 with a Doctor notes and prescritpion and for child#2 doctor's notes and prescrition. Document will submit to LPA
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representative for the administration of the medication to the hild Health-Related Services: 1.. This documentation shall be kept in the child's record. This requirement was not met as evidence by. Based on children's#1 and #2 file review child#1 was indicated that needs epipen. Per Director no epipen available for child #1 and Child#2, epipen was provided without doctor's notes and prescription.
This poses an immediate Health and Safety risk to children in care.
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Type B
09/03/2021
Section Cited
HSC1596.7995

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1596.7995 Employees or volunteers at day care center; immunization requirements; records; exemptions(c) The day care center shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the day care center
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Per Director will provided copy of the immunization card of Staff#2 and #3 no later than 9/03/2021
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This requirement was not met as evidence by. Based on review of records staff #2 and #3 members records were missing immunization documentation Pertussis, MMR and Influenza . which poses a potential Health, Safety, or Personal Rights 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:Peter Flores
LICENSING EVALUATOR NAME:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/23/2021 05:03 PM - It Cannot Be Edited


Created By: Denise Miranda On 08/23/2021 at 02:47 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: WEST HOLLYWOOD CHILDREN'S ACADEMY
FACILITY NUMBER: 197408763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited
HSC
1596.8662(4)(b)(1)

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1596.8662(4)(b)(1) Mandated Reporting Certificate On and after January 1, 2018, a person who applies for a license to be a provider of a 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....
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Per Director, she will submit the certification of mandated reporter for staff#2,#3,$#4, #5 and #6. to LPA Miranda by 8/27/2021.
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This requirement is not met as evidenced by observation and records review conducted during today’s inspection, Staff#2,#3, #4,5 # and 6 did not have update Mandated Reporter Certificate. Tthis poses a potential risk to the health and safety risk of children in care.
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Type B
08/24/2021
Section Cited
HSC1596.841

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Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon

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Per Director, she will submit via email or fax the current/complete children Roster no later than tomorrow. 08.24.2021 to LPA Miranda.
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request. This requirement is not met as evidenced by: Director was unable to produce the complete children's roster. This poses a potential risk to the health and safety risk of 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:Peter Flores
LICENSING EVALUATOR NAME:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/23/2021 05:03 PM - It Cannot Be Edited


Created By: Denise Miranda On 08/23/2021 at 02:55 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: WEST HOLLYWOOD CHILDREN'S ACADEMY
FACILITY NUMBER: 197408763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2021
Section Cited
CCR
101229.1

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b) The person who brings the child to, and removes the child from, the center shall sign the child in/out. (c) A person who removes the child from the center during the day, and returns the child to the center the same day, shall sign the child in/out. This requirement does not met: Director was unable to
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Director, shall have sign in and out by paper or eletronic signutaure from the person who is legally brings and remove child from the facilty. A copy of the sign in and sign out dated tomorrow 08/24/2021 shall be submitt to LPA Miranda.
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provide a copy of the sign in and out that it is showing the full signature from person who brings the child to, and remove the child from.
this poses a potential risk to the health and safety risk of 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:Peter Flores
LICENSING EVALUATOR NAME:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021


LIC809 (FAS) - (06/04)
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