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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197420046
Report Date: 09/02/2021
Date Signed: 09/02/2021 11:18:11 AM

Document Has Been Signed on 09/02/2021 11:18 AM - 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:VAN NUYS PRESCHOOLFACILITY NUMBER:
197420046
ADMINISTRATOR:MOON, MONICAFACILITY TYPE:
850
ADDRESS:6260 TYRONE AVENUETELEPHONE:
8188496705
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY: 60TOTAL ENROLLED CHILDREN: 0CENSUS: 18DATE:
09/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Young Moon, Director Assistant TIME COMPLETED:
11:00 AM
NARRATIVE
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On 09/02/2021 at 8:24AM, Licensing Program Analyst (LPA) Denise Miranda conducted an unannounced inspection at Van Nuys Preschool, located at 6260 Tyrone Ave, Van Nuys, CA 91401 for the purpose of following up on the self-reported unusual incident that occurred at the facility on 08/03/2021. The report was received via phone call on 08/05/2021 Unusual Incident/Injury Report (UIR) (LIC 624) was mailed to the El Segundo Child Care Regional Office and received on 08/09/2021. LPA observed 18 children in care with 4 staff and Director Assistant.

According to the Unusual Incident/Injury Report (UIR) that the Department received, on 08/09/2021, around napping time, child#1 shows his private area to child#2. This happened while child#1 was using the toilet located inside of the classroom: yellow.

During this inspection, LPA conducted an interview with Director Assistant and another party involved in the incident. LPA obtained copy of children's roster.

During inspection, LPA requested copies of the sign in and out for the following days : 08/3/2021 and 09/2/2021. Director Assistant was not able to produce copies of the sign in and out.
Please see LIC809-D.

At this time, further investigation is needed. An exit interview was conducted with Young Moon, Director Assistant.
SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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 09/02/2021 11:18 AM - It Cannot Be Edited


Created By: Denise Miranda On 09/02/2021 at 10:51 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: VAN NUYS PRESCHOOL
FACILITY NUMBER: 197420046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2021
Section Cited
CCR
101229(b)

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Sign in and sign out. The person who brings the child to, and removes the child from, the center shall sign the child in/out.
This requirement is not met as evidenced by: On 09/02/2021, Director Assistant is using a electronic sign in and out and was not able to print the sign in and out requested of the days 8/3/2021 and 9/2/2021.
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Per Director she will start today the sign in and out on the paper.
Director will submit the eletronic format of the sign in and out - 08/3/2021 and 09/2/2021.
no later than Monday 9/6/2021 to LPA Miranda via email.
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This is a Type B citation and poses a potential health and safety risk to children.
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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:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
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