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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416900
Report Date: 06/01/2023
Date Signed: 06/05/2023 03:53:24 PM

Document Has Been Signed on 06/05/2023 03:53 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:107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD STARTFACILITY NUMBER:
197416900
ADMINISTRATOR:ALETA WILLIAMSFACILITY TYPE:
850
ADDRESS:146 EAST 107TH. STREET ROOM K4TELEPHONE:
(323) 756-8137
CITY:LOS ANGELESSTATE: CAZIP CODE:
90003
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Monica Williams, Facility RepresentativeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 6/1/23 at 12:30 PM. LPA met with Monica Williams, Facility Representative (FR) who guided analyst on a tour of the facility.

There were 16 children and two staff present when LPA arrived. This is a full day preschool program, operating 8:00AM to 2:19PM. Facility is on the campus of 107th St Elementary in Room K-4. 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. Facility will be on Summer vacation, 6/9-8/15/23.

LPA toured Classroom K-4. Classroom furniture was in good condition, free of loose, sharp and/or pointed parts. The floors and surfaces in the classrooms were clean and safe. Water is made readily available by via operable water fountain and water bottles brought from home and provided by facility. LPA observed extra water bottles on hand in the classroom. Children have cubbies to store personal belongings. LPA observed children napping on mats. Sheets are provided by the facility and washed weekly. Parents provide blankets and take them home weekly to wash. Per FR there are currently no children with medication. Facility has completed required water lead testing. Lead exceedance found has been corrected. Posting of lead results

LPA toured the children’s restrooms located inside preschool classroom. LPA observed a waiver on file for shared restroom. Preschool shares restroom with a Transitional Kindergarten class (ETK). Restrooms were observed to be safe and sanitary with operable sinks and toilets.

LPA toured the outdoor play area. Outdoor area was observed to have age appropriate toys and material for children, free of loose, sharp, and/or pointed parts. LPA observed required cushioning under climbing structure to absorb fall. Shade was observed in the outdoor area via large trees and water was observed to be readily available via operable water fountains and fill stations. -------------------PAGE 1
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900
VISIT DATE: 06/01/2023
NARRATIVE
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 Outdoor area is also used by the ETK program. Waiver on file for staggered play outdoors.

LPA reviewed Sign In/Out sheets located in the classroom. All children were signed in with the date, time, and full signature of child's guardian.

LPA reviewed required posted documentation located in the classroom, which included, Facility License, Publication (PUB) 393- Notification of Parent Rights, PUB 269- Child Passenger Restraint System and Licensing Form LIC 613A- Notification of Personal Rights. Staff was reminded that the Lunch/Snack Menu must be posted.

Facility records were reviewed for 9148- Earthquake Preparedness form and (LIC) 610- Facility Disaster Plan. Disaster drill was last drill conducted 5/2023. All items were observed.

Children’s records were reviewed for Emergency Card with signed medical consent, Immunization Records, LIC 995 Notification of Parents’ Rights, LIC 701- Physician’s Report, LIC 613A- Personal Rights, and signed Admissions Agreement. Two out of four files were missing Physician's report. All documents were observed.

Staff records were reviewed at 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. Staff Two (S2) and S3 are missing mandated reporter training and immunization records.

LPA observed the kitchen located on the elementary campus. Facility provides AM snack, Lunch and PM snack. Food is not cooked at the facility. Prepackaged food is delivered daily. Extra food is discarded. Kitchen was observed to be clean, free of litter, insects and rodents. Trash cans outdoors and in the kitchen have tight fitting lids for solid waste. Staff was reminded that is solid waste is thrown in the classroom, the trash cans need lids. Cleaning supplies are stored separate from the food. Carbon monoxide detector is wired with the facility smoke/fire alarm.

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 ----------------------PAGE 2
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900
VISIT DATE: 06/01/2023
NARRATIVE
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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.

Facility representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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

Exit interview conducted and report was reviewed with the Facility Representatives, Monica Williams.



----------------------PAGE 3
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/05/2023 03:53 PM - It Cannot Be Edited


Created By: Denise Gibbs On 06/01/2023 at 01:58 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

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 FILE FOR STAFF S2 AND S3, 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, request the documents from S2, gather her own information for her file and email proof to LPA by POC date 8/15/23 when school is back in session.
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 TWO OUT OF THREE STAFF FILE FOR STAFF S2 AND S3, 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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2
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Per FR, she will take the training and have S2 take the training and email proof to LPA by POC date 8/15/23 when school is back in session.
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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/05/2023 03:53 PM - It Cannot Be Edited


Created By: Denise Gibbs On 06/01/2023 at 01:58 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101215.1(m)
Child Care Center Director Qualifications and Duties
(m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866.

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. HEALTH AND SAFETY TRAINING MISSING FOR S3, 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, she will take the training and email proof to LPA by POC date 8/15/23 when school is back in session.
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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
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