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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415233
Report Date: 05/22/2023
Date Signed: 05/22/2023 02:04:05 PM

Document Has Been Signed on 05/22/2023 02:04 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
MONTEREY PARK S WEST, 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: 16DATE:
05/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Jose , Facility RepresentativeTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Denise Gibbs and Lilia Hernandez conducted an unannounced annual required inspection at the above facility on 5/22/23 at 9:00AM. LPA met with Victor Lopez, Facility Representative (FR).

This is a preschool program that operates currently two sessions: Monday - Friday AM, 8:00AM-11:00AM and PM,11:30PM -2:30PM. Facility will be closed for Summer vacation from 6/9/23-8/15/23. When program starts in August operation hours will be full day, Monday-Friday, 7:45am -2:09PM.

There were 16 children and three staff present when LPAs 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.

LPAs toured Classroom #23. Classroom had furniture in good condition, free of loose, sharp and/or pointed parts. The carpet in the classroom was observed to be off colored, with dark spots throughout the carpet. Rug was observed to be flat on the ground to avoid tripping hazards. LPAs observed a "PPE" station in the classroom on a low shelf accessible to children containing Lysol, disinfectant wipes, and hand sanitizer. In an unlocked storage cabinet LPAs observed Premium Paint and Primer and disinfectant wipes on a low shelf. Water is made readily available via operable water fountain in the classroom. LPAs observed water bottles on hand for the children. Children cubbies to store extra clothes. Children's backpacks are hung on the backs of their chairs. Currently children do not nap at facility because the programs are half day. When program resumes in the Fall, children will be offered a rest time, with napping equipment. Per office staff there are no children currently taking medication. Facility has completed required water lead testing. Lead exceedance found in water has been corrected. LPAs discussed posting lead results with the facility.

LPAs toured the children’s restrooms. Preschool has access to a restroom through their classroom. Restroom has two doors allowing UTK to share the restroom. -------------PAGE 1
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: RUSSELL ELEMENTARY SCHOOL
FACILITY NUMBER: 197415233
VISIT DATE: 05/22/2023
NARRATIVE
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LPAs observed children using the elementary restrooms outside the licensed area. Staff were supervising at all times and children were not co-mingling. Per classroom staff, when they take the whole group the restroom, they use the bigger restroom. LPAs inspected the path to the restrooms and supervision plan for children. There is a waiver on file for shared restroom space. Restrooms were observed to be safe and sanitary with operable sinks and toilets.

LPAs 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. LPAs observed 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. LPAs did not observe any hazards in the outdoor space. Per FR, there are no weapons or firearms stored at the facility and there is no smoking allowed on the premises.

LPAs reviewed required posted documentation on 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. LPAs did not observe waivers (waivers were posted during last annual inspection) or Menu.

Facility records were reviewed for LIC 9040- Facility Roster, 9148- Earthquake Preparedness form, Daily schedules and Disaster drill log. Last drill conducted on 5/17/23 . All items were observed.

Facility provides Breakfast and Lunch. Food is not cooked at the facility. Prepackaged food is delivered daily. Extra food is sent discarded. 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 alarm system.

LPAs reviewed Sign In/Out sheets located in the classroom. LPAs observed one children not signed in and 12 out 16 children did not have sign in times.

Children’s records were reviewed for Emergency Card, Immunization Records, Licensing Form (LIC) 627- --------------PAGE 2
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
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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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: RUSSELL ELEMENTARY SCHOOL
FACILITY NUMBER: 197415233
VISIT DATE: 05/22/2023
NARRATIVE
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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 with FR. The school year will end 6/9/23. LPAs provided technical violations for the forms.

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 or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse, Transcripts or Permit and current Mandated Reporter Training Certificate. LPAs observed one out of three staff missing proof of immunization, two out of three staff are missing your mandated reporter. LIC 9108 and LIC9052 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.

Earthquake preparation form, LIC9108, LIC9052 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.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be ------PAGE 3

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
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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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: RUSSELL ELEMENTARY SCHOOL
FACILITY NUMBER: 197415233
VISIT DATE: 05/22/2023
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maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

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 Victor Lopez.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2023 02:04 PM - It Cannot Be Edited


Created By: Denise Gibbs On 05/22/2023 at 11:56 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: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA's observed Lysol, can of interior wall paint, disinfectant wipes, hand sanitizer a accessible to children, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2023
Plan of Correction
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Per FR, he will speak with the teacher about the chemicals in the classroom. One of the storage cabinets will be used for chemical and will remain locked at all times. Hand sanitizer will kept on a higher self out of children's reach. FR will email a picture of chemicals in cabinet/chemicals locked and storage of sanitizer out of reach by POC date 5/23/23.
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:Karen Chambers
LICENSING EVALUATOR NAME:Denise Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2023 02:04 PM - It Cannot Be Edited


Created By: Denise Gibbs On 05/22/2023 at 11:56 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: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(a)
Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA's observed soiled carpet, children's jacket piled on top of each other, various electrical cords on the floor, storage boxes in children's play space, outlets missing covers, accessible staff personal items (purses, bags, laptop bags) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2023
Plan of Correction
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Per FR, he will have a conversation with the staff in the classroom, staff will put personal items in the specified storage cabinet, outlet covers can be ordered if needed, the carpet will be cleaned or replaced during summer break. FR will send picture of a clean or replaced carpet, labeled storage for teacher's personal items and send to LPA by POC date 8/15/23.
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 four staff files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2023
Plan of Correction
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Per FR, he will ask staff to bring in proof of immunization and email to LPA by POC date 8/15/23.
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:Karen Chambers
LICENSING EVALUATOR NAME:Denise Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


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Document Has Been Signed on 05/22/2023 02:04 PM - It Cannot Be Edited


Created By: Denise Gibbs On 05/22/2023 at 11:56 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: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 four staff files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
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Per FR, mandated reporter training for the school is being done tomorrow. State preschool staff will be given time to complete State trainings. FR, will email certificates to LPA by POC date 5/31/23
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. One child was not signed in and 12 out of 16 children did not have sign in times, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
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Per FR, he will speak to staff and have her remind parents to sign in all children and document the time. FR will email a picture of completed sign in sheet by 5/31/23.
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:Karen Chambers
LICENSING EVALUATOR NAME:Denise Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


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