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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415074
Report Date: 02/23/2022
Date Signed: 02/23/2022 12:10:04 PM

Document Has Been Signed on 02/23/2022 12:10 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:HART VILLAGE EARLY EDUCATION CENTERFACILITY NUMBER:
197415074
ADMINISTRATOR:EDUARDO VILLEDAFACILITY TYPE:
850
ADDRESS:21702 HART STREETTELEPHONE:
(818) 274-0174
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: DATE:
02/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:EDUARDO VILLEDATIME COMPLETED:
12:29 PM
NARRATIVE
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On 02/23/2022, Licensing Program Analyst (LPA) Laticia Thompson conduct an unannounced visit to deliver finding for complaint # 30-CC-20211201121234. During the course of the investigation based on interviews conducted a Case Management Deficiency was discovered. See LIC 809D Attached

ยท The facility failed to provide parents with a report of an unusual incident that occurred on 11/30/22.

Licensee was cited a Type B. An exit interview was conducted with the director. A copy of this report was read and issued to the director along with a copy of the Notice of Site Visit and appeal rights.

SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Laticia S Thompson
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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 02/23/2022 12:10 PM - It Cannot Be Edited


Created By: Laticia S Thompson On 02/23/2022 at 11:33 AM
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: HART VILLAGE EARLY EDUCATION CENTER
FACILITY NUMBER: 197415074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2022
Section Cited
CCR
101212(f)

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101212 Reporting Requirements (f)The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representativeThis requirement was not met as evidence by
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The director will provide a written report to parents or authorized representaives within 24hours of any unusual incdient that occurrs involving the children at the facility, per title 22 section 101212
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Based on LPA's interviews with parents and witness, parents were not provided a report of an unusual incident that occured on at the facility between C#1 and C#4. Which posses a potential Health and Safety or Personal Rights risk to children under 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:Laticia S Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022


LIC809 (FAS) - (06/04)
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