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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415233
Report Date: 06/01/2022
Date Signed: 06/16/2022 01:03:10 PM

Document Has Been Signed on 06/16/2022 01:03 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:RUSSELL ELEMENTARY SCHOOLFACILITY NUMBER:
197415233
ADMINISTRATOR:JOHN P. SAYERSFACILITY TYPE:
850
ADDRESS:1263 EAST FIRESTONE BLVD. #20TELEPHONE:
(323) 582-7247
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 21TOTAL ENROLLED CHILDREN: 21CENSUS: 8DATE:
06/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:John Sayers, Facility RepresentativeTIME COMPLETED:
12:30 PM
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 THIS IS AN AMENDED REPORT
Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 6/1/22 at 9:25AM. LPA met with John Sayers, Facility Representative (FR) who guided analysts on a tour of the facility. (Language changed to correct date and time)

This is a preschool program that operates two sessions: AM, Monday - Friday from 8:00AM-11:00AM and PM, Monday - Friday, 11:30PM -2:30PM. Facility will be closed for Summer vacation from 6/10/22-8/15/22.

There were eight children and three staff present when LPA arrived. Facility is in compliance with license capacity and Title Five ratio guidelines. All individuals present have obtained a criminal record clearance or criminal record exemption as a condition of employment with the Los Angeles Unified School District.

LPA toured Classroom #23. Classroom had furniture in good condition, free of loose, sharp and/or pointed parts. The floors and surfaces in the classroom were clean and safe. Rugs were observed to be flat on the ground to avoid tripping hazards. Water is made readily available via water bottles brought by the children and a water fountain in the classroom. Per Staff One (S1) there are no children currently taking medication. Children cubbies to store personal belongings separate from each other. Children do not nap at facility because the programs are half day. LPA toured the children’s restrooms. Restrooms were observed to be safe and sanitary with operable sinks and toilets. LPA observed that children are using restrooms outside the licensed area. Per FR, the restroom for the preschool children are being remodeled. LPA discussed Unusual incident reporting with FR. LPA inspected the path to the restrooms and supervision plan for children. There is a waiver on file for shared restroom space.

LPA toured outdoor play area. There is a waiver on file for shared yard space. Outdoor area was observed to have age appropriate toys and material for children, free of loose, sharp, and/or pointed parts. LPA observed -------------PAGE 1
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2022
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 5
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: RUSSELL ELEMENTARY SCHOOL
FACILITY NUMBER: 197415233
VISIT DATE: 06/01/2022
NARRATIVE
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required cushioning under climbing structure to absorb fall. Shade was observed throughout the outdoor area. Water bottles are taken outdoors for children and water fountains are available. LPA observed a planned special event taking place away from the Preschool children with the Transitional Kindergarten class. LPA did not observe any hazards. Per FR, there are no weapons or firearms stored at the facility and there is no smoking allowed on the premises.

LPA observed required posted documentation for the parent board, which included, Facility License, Outdoor and Restroom Waiver, Publication (PUB) 393- Notification of Parent Rights, Licensing Form (LIC) 610- Facility Disaster Plan, PUB 269- Child Passenger Restraint System, LIC 613A- Notification of Personal Rights and Lunch/Snack Menu. All items were observed.

Facility records were reviewed for LIC 9040- Facility Roster, 9148- Earthquake Preparedness form, Daily schedules and Disaster drill log, last drill conducted on 5/25/2022. All items were observed.

LPA toured the kitchen on site. Facility provides AM snack, PM snack and lunch. Food is not cooked at the facility. Prepackaged food is delivered daily. Extra food is sent home with the children. Kitchen was observed to be clean, free of litter, insects and rodents. Trash cans for solid waste have tight fitting lids. Cleaning supplies are stored separate from the food. Carbon monoxide detector is connected to the smoke ar lam system.

LPA reviewed Sign In/Out sheets located in the classroom. All children present were signed in with date, time and full signature of the teacher who receives the child. Due to COVID-19 precautions, parents are not entering the facility. Children are dropped off and picked up at the main entrance. A digital daily pass (approved child health assessment) is scanned for added precaution.

Children’s records were reviewed for Emergency Card, Immunization Records, Licensing Form (LIC) 627- Consent for Medical Treatment, LIC 995 Notification of Parents’ Rights, LIC 701- Physician’s Report, LIC 613A- Personal Rights, and signed Admissions Agreement. Documents were discussed.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC 9052- Employee Rights, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance --------------PAGE 2
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: RUSSELL ELEMENTARY SCHOOL
FACILITY NUMBER: 197415233
VISIT DATE: 06/01/2022
NARRATIVE
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or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse, Transcripts or Permit and current Mandated Reporter Training Certificate. LPA observed that two out of three staff are missing proof of immunization and all staff are missing Mandated Reporter training certificate. Items were discussed.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment. LPA observed that facility still is implementing COVID-19 precautions and procedures as required by Los Angeles Unified School District and the Department of Public Health.

New Car Seat Law poster, Copy of blank Unusual Incident form, LIC 624 and Lead Flyer was provided.

Incidental Medical Services (IMS):
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a plan for providing 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

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

Exit interview conducted and report was reviewed with the Facility Representative John Sayers. ------PAGE 3

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/01/2022 12:16 PM - It Cannot Be Edited


Created By: Denise Gibbs On 06/01/2022 at 11:19 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: RUSSELL ELEMENTARY SCHOOL
FACILITY NUMBER: 197415233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022

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 record review, the licensee did not comply with the section cited above in two out of three staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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Facility Representative states that staff will bring in proof of immunizations when school reopens 8/15/22 and email them to LPA.
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 record review, the licensee did not comply with the section cited above in three out of three staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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Facility Representative states that staff will bring in proof of traning when school reopens 8/15/22 and email them to LPA.
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:Trevino Cochran
LICENSING EVALUATOR NAME:Denise Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/01/2022 12:16 PM - It Cannot Be Edited


Created By: Denise Gibbs On 06/01/2022 at 11:19 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: RUSSELL ELEMENTARY SCHOOL
FACILITY NUMBER: 197415233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
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:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, licensee did not provide proof of CPR and first aid, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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FR states that he will get an instruntor to come to the school and traning staff. Staff will have proof of traning when school reopens on 8/15/22. FR will email LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Trevino Cochran
LICENSING EVALUATOR NAME:Denise Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022


LIC809 (FAS) - (06/04)
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