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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416902
Report Date: 04/13/2023
Date Signed: 04/13/2023 02:14:11 PM

Document Has Been Signed on 04/13/2023 02:14 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:99TH STREET ELEMENTARY SCHOOL CSPP/HEAD STARTFACILITY NUMBER:
197416902
ADMINISTRATOR:MARISSA BORDONFACILITY TYPE:
850
ADDRESS:9900 S.WADSWORTH AVE.RMS 12,13TELEPHONE:
(323) 564-2677
CITY:LOS ANGELESSTATE: CAZIP CODE:
90002
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 17DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Melinda Fulton, Facility RepresentativeTIME COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Denise Gibbs and Rosaura Valenzuela conducted an unannounced annual required inspection at the above facility on 4/13/23 at 10:00AM. LPAs were met by Melinda Fulton Facility Representative (FR). LPAs were directed to the Preschool classroom and conducted inspection.

This is a preschool program that operates two sessions: AM Session, 8:00AM-11:00AM and PM Session,12:00PM-3-00PM, Monday-Friday. There were 17 children and two staff present when LPAs arrived.

LPAs toured Classroom #33. Classroom had furniture in good condition, free of hazards. The floors and surfaces in the classroom were clean and safe. Rugs were observed to be flat on the ground to avoid tripping hazards. Facility has age appropriate toys and material for children in care. LPAs did observe multiple outlets without safety covers. Water is made readily available via water bottles provided by facility. LPAs observed extra water bottles in storage. There is a water fountain in the classroom but it was observed to be shut off. Per FR there are no children currently taking medication. Children have hooks to store personal belongings separate from each other. Children do not nap at facility due to program time. Facility has conducted required lead water lead testing and corrected lead exceedance. LPAs did not observe lead results posted.

LPAs toured the children’s restroom located inside the preschool classroom. Restroom is only used by preschool children. Restroom was observed to be safe and sanitary with operable sink and toilet. Restroom in the classroom has one toilet. There is a waiver on file for shared use of the elementary restroom.

LPAs toured outdoor play area. Preschool uses the front play area. Outdoor area was observed to have age appropriate toys and material for children, free of hazards. LPA observed required cushioning under climbing structure to absorb fall. Shade was observed throughout the outdoor area via large trees. Water bottles are taken outdoors so children can drink freely. The yard was observed to be clean and free of hazards. Per FR, there are no weapons or firearms stored at the facility and there is no smoking allowed on the premises. ---------------------PAGE 1
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902
VISIT DATE: 04/13/2023
NARRATIVE
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LPAs reviewed required posted documentation on the parent board located inside the classroom, which should included, Facility License, Outdoor and Restroom Waiver, Publication (PUB) 393- Notification of Parent Rights, Licensing Form (LIC) 610- Facility Disaster Plan, LIC 9148- Earthquake Preparedness form, PUB 269- Child Passenger Restraint System, LIC 613A- Notification of Personal Rights and Lunch/Snack Menu. All documents observed.

Facility records were reviewed which included, LIC 9040- Facility Roster, daily schedules and Disaster drill log, last drill conducted on 3/27/23. Documents were observed.

LPAs 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/fire alarm system at the facility.

LPA reviewed Sign In/Out sheets located in the classroom. All children were sign in with full names of child's representative. All children were missing sign in and out times for the week.

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.

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.

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

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
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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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902
VISIT DATE: 04/13/2023
NARRATIVE
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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 Melinda Fulton.

------PAGE 3

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

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/13/2023 02:14 PM - It Cannot Be Edited


Created By: Denise Gibbs On 04/13/2023 at 12:40 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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(a)
Disaster and Mass Casualty Plan
(a) Each licensee shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.

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, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Per FR, She will fill out the form and email LPA a copy by 4/28/23.
Type B
Section Cited
WD
100700(c)(1)
Written Directives for Lead Testing
(1) For a license issued on or after July 1, 2022, initial testing results shall be received and posted within 180 days of licensure.

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, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Per FR, the results of the lead test will be located and results will be posted, and a picture to LPA by POC date 4/28/23
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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/13/2023 02:14 PM - It Cannot Be Edited


Created By: Denise Gibbs On 04/13/2023 at 12:40 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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

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 3 OUT OF 3 STAFF FILES which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Per FR, staff will be asked to bring in immunization and she will email LPA proof by POC date 4/28/23
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 3 OUT OF 3 STAFF FILES which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Per FR, she will have staff take the training as soon as possible and email LPA proof by POC date 4/28/23.
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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/13/2023 02:14 PM - It Cannot Be Edited


Created By: Denise Gibbs On 04/13/2023 at 12:40 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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

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 in ONE OUT OF ONE STAFF FILES, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Per, FR she will talk to the Principal about taking the training and email proof of completion by POC date 4/28/23
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 FOR AT LEAST ONE STAFF ON SITE which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Cleared during inspection.
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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/13/2023 02:14 PM - It Cannot Be Edited


Created By: Denise Gibbs On 04/13/2023 at 12:40 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: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 OUT OF 5 CHILDREN'S FILES which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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3
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FR, she will follow up with the parents and have get a physician report completed. FR will email a copy to LPA by POC date 4/28/23
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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2
3
4
Based on record review, the licensee did not comply with the section cited above in 17 OUT OF 17 SIGNATURES, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
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2
3
4
Per FR, she will have parents start documenting the times of drop off and pick up today. FR will email sign in/out sheets with times for 4/14/23.
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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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